The patient 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 patient is now at 6 cm

Question

The nurse understands that the most important nursing action for this patient is to:
1. Assist the patient 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.

Answer 1

Correct Answer: 1
Rationale 1: Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.
Rationale 2: A patient with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean. This patient 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.
Rationale 3: The cervix is normally assessed when the patient'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 patient was in the active phase of labor and cephalopelvic disproportion was a risk. Every eight hours is too far apart.
Rationale 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.