Health Promotion and Maintenance
79. A client, who is gravida 1, para 0, is admitted to labor and delivery with spontaneous rupture of membranes. A vaginal examination reveals clear fluid and the cervix is 2 cm dilated. Based on the information provided, which statement should a nurse expect this client to make?
. "We have a name picked out for the baby."
. "I need to push when I have a contraction."
. "I can't concentrate if anyone is touching me."
. "When can I get my epidural?"
Test-Taking Tip
The best answer is based on identifying the stage and phase of labor based on her cervical dilation, and the typical response of a woman in the latent phase of labor.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is correct because this client is a primigravida at 2 cm dilated. This is the first stage of labor, and latent phase. Typically, clients in this stage of labor are not in much pain, and are excited and talkative about what is happening. Answer 2 is incorrect because the urge to push during a contraction occurs during the transition phase of labor, not the latent phase. Answer 3 is incorrect because inability to concentrate during a contraction happens during the active phase of labor, not the latent phase of labor. Answer 4 is incorrect because clients usually ask for an epidural when they are in pain during the active or transition phase of labor. The epidural is generally given when the client is in active labor, not latent phase.