The nurse is caring for a laboring patient. A cervical exam indicates 8 cm dilation. The patient is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important?
1. Leave the patient alone so she can rest.
2. Ask the family to take a coffee-and-snack break.
3. Encourage the patient to have an epidural for pain.
4. Reassure the patient that she will not be left alone.
4
Rationale 1: The patient is in the transitional phase of the first stage of labor, and will not want to be alone.
Rationale 2: The patient is in the transitional phase of the first stage of labor. The family members might want to take a break, but the patient will not want to be alone.
Rationale 3: The patient is in the transitional phase of the first stage of labor. There is no indication that the patient wants pain relief.
Rationale 4: Because the patient is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the patient and reassuring her that she will not be alone are the highest priorities at this time.
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