The primiparous client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. How should the nurse respond to this client?
1. "What did you expect? You have only had contractions for a few hours. Labor takes time."
2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now."
3. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."
4. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
4
Explanation:
1. This reply is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a primipara averages 12 to 24 hours, the nurse must always be therapeutic in all communication.
2. The perineal body thinning primarily occurs during the second stage of labor; it is not expected now.
3. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.
4. 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 longer than do subsequent labors and births.
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