A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?

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Quizplus · Accepted Answer

Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client's anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

A Gravida 1, Para 0, 38 Weeks' Gestation Is in the Transition