A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action?

Question

Quizplus · Accepted Answer

11ecbb05_cc05_69db_b433_0f6d81fb7d59_MD0009_00 The period of active labor from 8-10 cm dilation (ie, "transition") is often the most emotionally challenging phase of labor, marked by increased maternal anxiety. A mixture of mucus and pink/dark brown blood ("bloody show") is commonly observed during transition. Nursing priorities include providing emotional support and encouragement, and coaching the client in breathing techniques (Option D). (Option A) Meperidine (Demerol) is an opioid occasionally prescribed for analgesia during early labor. It has a rapid onset (5 minutes) when given IV, and a duration of 2-3 hours. However, it should be avoided within 1-4 hours of birth due to the potential for neonatal respiratory depression. (Option B) The second stage of labor begins once complete dilation (10 cm) is achieved. Clients may feel the urge to push (Ferguson reflex) prior to complete dilation if the fetal head is low in the pelvis. However, pushing should be delayed until complete dilation is achieved to avoid cervical swelling and/or cervical lacerations. (Option C) Although lithotomy positioning may be more convenient for the birth attendant, upright or lateral positions encourage fetal rotation and descent, increase client comfort, and decrease the risk of perineal trauma. This client has not yet reached complete dilation and should be allowed to move freely. Educational objective: The period of active labor from 8-10 cm dilation (ie, "transition") can be emotionally challenging for laboring clients. Signs of near-complete dilation include bloody show and the urge to push. Clients should be coached in breathing techniques and should avoid pushing until fully dilated to prevent cervical trauma.

A Client in Labor Has Reached 8 Cm Dilation, Is