The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and -2. An epidural was administered shortly thereafter
Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and -2. What is the nurse's next action?
a. Palpate the patient's bladder for fullness.
b. Contact the health care provider for a prescription to augment the labor.
c. Obtain an order for an internal pressure catheter.
d. Reassure the patient that she is making adequate progress.
ANS: A
The fetal presenting part is expected to descend at a minimal rate of 1 cm/hr in the nullipara and 2 cm/hr in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.
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