Practice Question
A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at +1 station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?
Answer Choices:
Correct Answer:
Have the client pant during the next few contractions.
Rationale:
🟠 At 7 cm dilation and 100% effacement, the client is in the active phase of labor but not yet fully dilated (which occurs at 10 cm).
🟠 The urge to push before full dilation can cause cervical swelling and trauma, potentially prolonging labor or causing complications.
🟠 Encouraging the client to pant during contractions helps her control the urge to push, delaying pushing until full dilation is reached.
🟠 This controlled breathing technique supports safer labor progression and reduces the risk of maternal fatigue and fetal distress.
🟠 Assessing for crowning or helping to empty the bladder are appropriate later in labor, but immediate focus should be on managing premature pushing.
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This question is from RN ATI Maternity Exam V which contains 43 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 4