The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important?
1. Leave the client alone so she can rest.
2. Ask the family to take a coffee-and-snack break.
3. Encourage the client to have an epidural for pain.
4. Reassure the client that she will not be left alone.
4
Rationale:
1. The client is in the transitional phase of the first stage of labor, and will not want to be alone.
2. The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone.
3. The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief.
4. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time.
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