A client who is 39 weeks gestation calls the labor and delivery unit to report that she is experiencing mild, irregular contractions. She tells the practical nurse (PN) that the healthcare provider examined her in the clinic today, and her cervix was 3 cm dilated, with intact membranes, and the presenting part was at -1 station. Which intervention should the PN implement?
A.
Tell her to empty her bladder and call if she has a bloody show.
B.
Direct her to come to the unit for impending delivery.
C.
Ask the charge nurse for further instructions.
D.
Encourage ambulation until the contractions are regular.
The correct answer and Explanation is :
The correct answer is A. Tell her to empty her bladder and call if she has a bloody show.
Explanation:
At 39 weeks gestation, the client is considered to be at term, and the presence of mild, irregular contractions could indicate the onset of labor. However, the information provided about her current status—3 cm dilation, intact membranes, and the presenting part at -1 station—suggests that she is in early labor or the latent phase of labor.
Here’s a breakdown of why A is the most appropriate intervention:
- Current Labor Stage: The client’s cervix is 3 cm dilated, which indicates she is in the early stage of labor. In early labor, contractions are usually mild and irregular, and the cervix is progressing but not fully effaced or dilated. This phase can last for several hours to days, and it’s essential to monitor the progression carefully.
- Intact Membranes: Since the membranes are still intact, it’s crucial to monitor for any signs of membrane rupture, such as a “bloody show” or leaking amniotic fluid. The bloody show indicates that labor may be progressing and that the cervix is continuing to change, but it is not an immediate sign of active labor.
- Bladder Emptying: Encouraging the client to empty her bladder can help alleviate discomfort and may also help facilitate labor progress. A full bladder can impede the descent of the fetus and make contractions less effective.
- Monitoring for Bloody Show: Advising the client to call if she experiences a bloody show is important as it can be a sign that labor is moving into a more active phase. It provides a clear criterion for when she should come to the hospital.
B is not appropriate because directing the client to come to the unit for impending delivery would be premature given her current status.
C is not necessary at this point as the PN can provide clear guidance based on the client’s current labor stage and symptoms.
D is not recommended because encouraging ambulation might not be beneficial if the contractions are irregular and mild, and could be counterproductive if it’s early labor.
In summary, option A ensures that the client is given appropriate advice for managing early labor and provides clear instructions on when to seek further help.