The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in three hours of contractions occurring every five 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."
Correct Answer: 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 less time than for subsequent labor and births.
Rationale 2: The perineal body thinning primarily occurs during the second stage of labor; it is not expected now.
Rationale 3: This reply is not therapeutic. Although it is true that this patient has only been in early labor for a short time, and it is true that labor for a primip averages 12–24 hours, 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...
A nurse manager is aware that U.S. citizenship is required by a job position being filled. How should the manager handle this requirement during the job interview?
1. Ask the applicant to provide proof of citizenship before the interview is scheduled. 2. Ask the applicant if he or she is an U.S. citizen. 3. Do not ask unless the applicant mentions citizenship. 4. Ask if the applicant's family is from the United States.
Lymph in the lymphatic system can be best described as which color?
a. clear c. slightly blood tinged b. pale yellow d. blood colored
A hospital employee brings a 9-year-old son to the emergency room with a spiral fracture of the tibia
The employee reports that the injury occurred when the boy's 5-year-old sister hit him with wooden bat. The injury is inconsistent with an impact and with the sister's strength. What should the nurse do in this situation? A) Tell the employee that the story is not plausible and ask what really happened B) Leave the treatment area and call the police C) Leave the treatment area and call the social services department in the hospital D) Let the hospital administrator know so that the hospital can take any necessary action
The nurse cares for a client who acquires a healthcare-associated infection while in an isolation environment. Which action will the infection control nurse take that best responds to the client's condition?
A. Plan staff education on isolation precautions and proper hand hygiene. B. Ask the client if he or she is performing hand hygiene. C. Examine isolation equipment outside the client's room. D. Plan staff education on the identification of client's at greatest risk for infection.