A nurse is assisting with the care of a client who is at 7 cm of cervical dilation and 100% effacement, and in active
labor.
The client informs the nurse that she needs to push.
Which of the following is the appropriate action for the nurse to take?

Choice A rationale:

Checking the client’s blood pressure is important, but it is not the first action the nurse should take. Hypotension could

indicate hemorrhage, but the nurse needs to address the immediate risk of excessive bleeding.

Choice B rationale:

The nurse should first massage the client’s fundus. A saturated perineal pad could indicate a postpartum hemorrhage.

Massaging the fundus helps the uterus contract and may stop the bleeding.

Choice C rationale:

Observing for pooling of blood under the buttocks is a way to assess for bleeding. However, this is not the first action because

it does not address the cause of the bleeding.

Choice D rationale:

Administering oxytocin can help the uterus contract and reduce bleeding. However, this is not the first action because it

requires a physician’s order.

Choice A rationale:

Urinary retention is not a common sign of impending labor. In fact, it's more likely to occur in the early stages of pregnancy

due to hormonal changes and the pressure of the growing uterus on the bladder. As labor approaches, the baby's head often

descends into the pelvis, which can relieve some of the pressure on the bladder and make urination more frequent, not less

frequent.

Urinary retention can be a sign of other medical concerns, such as a urinary tract infection or problems with bladder function.

It's important to report any difficulty urinating to a healthcare provider for proper evaluation and treatment.

Choice B rationale:

A decrease in vaginal discharge is not typically associated with impending labor. On the contrary, many women notice an

increase in vaginal discharge, often referred to as "bloody show," as labor approaches. This discharge is typically pink or

brownish in color and may contain streaks of blood. It's caused by the release of the mucus plug that seals the cervix during

pregnancy.

A decrease in vaginal discharge could be a sign of other issues, such as a decrease in amniotic fluid or a yeast infection. It's

important to report any changes in vaginal discharge to a healthcare provider for assessment.

Choice D rationale:

A weight gain of 0.5 to 1.5 kilograms (1 to 3 pounds) is not a reliable sign of impending labor. Weight fluctuations are common

in late pregnancy due to factors such as fluid retention and changes in blood volume. Some women may even lose a small

amount of weight in the days leading up to labor.

While significant weight gain (more than 2 kilograms or 4 pounds in a week) could indicate a potential issue like preeclampsia,

a small weight gain or loss is not typically a cause for concern in terms of labor onset.

Choice C rationale:

A surge of energy, often referred to as "nesting instinct," is a common sign that labor may be approaching. This sudden burst of

energy can manifest as a strong urge to clean, organize, and prepare the home for the baby's arrival. It's thought to be caused

by a combination of hormonal changes and the body's natural instincts to prepare for childbirth.

While the exact timing of labor is unpredictable, experiencing a surge of energy, especially in conjunction with other signs like

increased Braxton Hicks contractions, lower back pain, or pelvic pressure, may suggest that labor is likely to start within the

next few days or weeks.