A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?
A.
Help the client to the bathroom to empty her bladder.
B.
Assist the client into a comfortable position.
C.
Have the client pant during the next few contractions.
D.
Assess the perineum for signs of crowning.
The Correct Answer and Explanation is:
The correct answer is D. Assess the perineum for signs of crowning.
Explanation
In the scenario provided, the client is multigravid (having had multiple pregnancies), is in active labor with 7 cm of cervical dilation, 100% effacement, and the fetus is at a 1+ station. The cervix is nearly fully effaced and dilated, and the fetus is descending through the pelvis. The client’s amniotic membranes are intact, and she suddenly feels the urge to push.
Here’s a detailed explanation for why D. Assess the perineum for signs of crowning is the appropriate response:
- Assessment of Progression in Labor: With the client at 7 cm dilation, she is in active labor. The urge to push typically occurs when the cervix is fully dilated (10 cm) and the fetus is at a lower station, usually around +1 station or lower. However, in multigravid women, they might feel the urge to push before reaching complete dilation due to their experience with labor. The nurse should first assess if the cervix has completed dilation and if there are any signs of crowning.
- Determining the Need for Immediate Intervention: Crowning refers to the appearance of the fetal head at the vaginal opening. If crowning is occurring, it means the fetus is very close to being born, and the client should be allowed to push. However, if the cervix is not fully dilated, pushing too early could cause cervical swelling or injury.
- Avoiding Unnecessary Interventions: Options A, B, and C involve actions that are not immediately relevant to the situation. Emptying the bladder (A) or assisting the client into a comfortable position (B) may be helpful in labor but do not address the urgent need to determine if the fetus is in the final stages of delivery. Having the client pant (C) can help avoid premature pushing but should be considered only after confirming the cervical status.
In conclusion, the priority is to evaluate the current stage of labor and fetal descent. If crowning is observed, this confirms the need for immediate action to prepare for delivery. Therefore, assessing the perineum for signs of crowning is the most appropriate response to ensure the safety of both the mother and the baby.