Difficulty: Medium
Average Score: 82%
Simulated
Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:
Correct answer
D
Rationale
Nausea, chills, perspiration, and irritability are signs of the transition phase (8ÔÇô10 cm dilation). Assessing cervical dilation and station confirms progression and guides care. Warming the room, increasing fluids, or administering antiemetics are secondary.