Difficulty: Medium
Average Score: 70%
Simulated
The nurse is assessing a client who has been admitted in active labor.The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom.What should be the nurse's first course of action?
Correct answer
C
Rationale
Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.