The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1C2 minutes; strong, large amount of “bloody show.”
The most appropriate nursing goal for this client would be:
A . Maintain client’s privacy.
B . Assist with assessment procedures.
C . Provide strategies to maintain client control.
D . Enlist additional caregiver support to ensure client’s safety.
Answer: C
Explanation:
(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority.
(B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance.
(C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client’s ability to cope is most threatened during this phase of labor, and nursing actions are directed toward helping the client to maintain control.
(D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.