Health Promotion and Maintenance
36. Several hours after admission to a birthing center, a client, who is gravida 1, para 0, is dilated 5 cm. The cervix is completely effaced and the fetus is at a +1 station. When a contraction begins, the client kneels on the bed, rests her upper body against her husband, closes her eyes, and sways slowly while humming softly. At the end of the contraction, her husband gently places her on her side and she rests with her eyes closed until the next contraction begins. Which is the most appropriate nursing action for this client?
Choices
. Offer her clear liquids.
. Offer her an epidural.
. Offer her pain medication.
. Encourage her to begin pant-blow breathing.
Question Hint
Test-Taking Tip
Two of the alternatives are essentially the same: offering an epidural and offering pain medication; therefore, eliminate both of those choices.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Go to Choices
Health Promotion and Maintenance
.
Answer 1 is correct because the client is coping well with her labor and, with the partner's support, is using prepared childbirth techniques. Offering clear liquids would be an appropriate nursing action during the active phase of labor. Answer 2 is incorrect because offering her an epidural when she is coping well is not an appropriate nursing action. If the client asked for pain relief, then offering an epidural would then be an appropriate option. Answer 3 is incorrect because offering her pain medication when she is coping well is not an appropriate nursing action. If the client asked for pain relief, then offering pain medication would be an appropriate option. Answer 4 is incorrect because pant-blow breathing is a technique used during transition phase of labor; this client is in the active phase of labor.
Go to Question