Which of the following should the nurse plan to do next?
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Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated 3 cm, 0 station and completely effaced; fetal heart rate of 136 BPM.
A. Prepare the client for epidural anesthesia to relieve pain. B. Turn the client from the left side-lying position to the right side-lying position. C. Instruct the client that internal fetal monitoring is necessary. D. Assist the client with comfort measures and breathing techniques.
Based on the different symptoms that the patient is exhibiting, she is in the first stage of labor. The best thing that the medical professional can do is letter D. This is to assist the client with comfort measures and breathing techniques. The breathing techniques can be effective in lessening the discomfort that the woman in labor is experiencing.
The woman is also encouraged to move around a bit in order to ease the discomfort further. If in case the patient decides to lie down, she should lie down on her left side. Epidural anesthesia should not be administered yet because the cervix is only at 3cm. This is only given when the cervix is already at 4-5cm. Since the fetus’ heart rate is normal, there is no need for fetal monitoring at this point.
Assist the client with comfort measures and breathing techniques.-the clients assessment findings indicate that the client is in the latent phase of the first stage of labor. therefore, the nurse should plan to assist the client with comfort measures and breathing techniques to relieve discomfort. the client can move around, walk, or ambulate at this phase of labor. if the client chooses to remain in bed, a left side-lying position provides the greatest perfusion. it is too early for the client to have an epidural anesthetic. epidural anesthesia is usually administered when the cervix is dilated 4 to 5 cm. the fetal heart rate is normal, so internal fetal monitoring is not warranted at this time.