A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes
The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment?
a. Use contact anesthesia for an epidural and prepare the client per protocol.
b. Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop.
c. Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth.
d. Call the physician for admitting orders.
ANS: C
By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the client's needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the client's concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician.
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