The client at term has a suspected small pelvis. The fetus has an estimated weight of 4,200 g (9 pounds, 4 ounces). Spontaneous labor has begun, and the client is now at 6 cm
The nurse understands that the most important nursing action for this client is to: 1. Assist the client to squat during the second stage.
2. Encourage oral fluids and carbohydrate intake.
3. Assess the cervix for change every eight hours.
4. Inform the couple that labor might be prolonged.
1
Rationale:
1. Squatting increases the diameter of the pelvic outlet, and might facilitate vaginal birth when cephalopelvic disproportion is a risk.
2. A client with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean. This client should either be given only clear liquids or be n.p.o. to reduce the risk of aspiration should a cesarean need to be performed.
3. The cervix is normally assessed when the client's labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a client were in the active phase of labor, and cephalopelvic disproportion were a risk. Every eight hours is too far apart.
4. Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority.
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