Health Promotion and Maintenance
31. A nurse performs a sterile vaginal examination on a multiparous client at 37 weeks' gestation. The client is 8 cm dilated, completely effaced, and a +1 station. She tells the nurse, "I can't keep myself from pushing when I have a contraction." Which nursing intervention is most appropriate in this situation?
. Encourage her to push through the last 2 cm of dilation.
. Assist the client to pant-blow at the peak of contractions.
. Readjust the fetal monitor.
. Tell the coach that it is not good for the baby if she pushes right now.
Test-Taking Tip
The goal of the question is to directly assist the client in coping with increased pressure. Look for the intervention that will provide direct support.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because pushing before the cervix is completely dilated can result in cervical tears. Answer 2 is correct because assisting the client to pant-blow at the peak of contractions will help her to avoid pushing before her cervix is completely dilated. Answer 3 is incorrect because readjusting the fetal monitor will not help the client avoid pushing and damaging her cervix. Answer 4 is incorrect because telling the coach that it is not good for the baby if she pushes right now is not directly helping the client avoid pushing and it is unnecessarily trying to scare her into compliance. The baby will not be affected by pushing too early.