The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. The best response by the nurse is:
1. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now."
3. "What did you expect? You've only had contractions for a few hours. Labor takes time."
4. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."
1
Rationale 1: Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much more time than do subsequent labors and births.
Rationale 2: The perineal body's thinning primarily occurs during the second stage of labor; it is not expected now.
Rationale 3: This reply is not therapeutic. The nurse must always be therapeutic in all communication.
Rationale 4: The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.
You might also like to view...
The nurse is assessing the pupils of a newborn. After ____________________ weeks, if no pupillary light reflex is present, blindness is indicated
Fill in the blank with correct word
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.
A nurse is being sued for malpractice. Which of the following specific elements must be present for the nurse to lose the case? (Select all that apply.)
______ Negligence ______ Damages ______ Injury ______ Malpractice ______ Causation ______ Foreseeability ______ Breach of duty ______ Duty
The nurse is evaluating telephone calls made by the mothers of newborns in a community clinic. Which calls should the nurse make a priority? Select all that apply
1. Mother who is 16 years old 2. Mother who is breastfeeding 3. Mother who is a single parent 4. Mother who gave birth to twins 2 weeks ago 5. Mother whose baby was born at 30 weeks' gestation