A client who is in active labor is admitted with her cervix dilated to 3 cm with 50% effacement and the presenting part at 0 station. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged. Which action should the PN implement?
Explanation & Rationale
A. Obtain a straight catheter kit to empty her bladder: Catheterization is an invasive procedure and should be reserved for clients unable to void independently or when bladder distension interferes with labor. Since the client can ambulate safely, catheterization is not the first choice. B. Review the fetal heart rate pattern: Monitoring the fetal heart rate is important during labor, but it does not address the client’s immediate need to void. Assessment of maternal comfort and mobility should be prioritized in this situation. C. Assist the client up to the bathroom: Helping the client to the bathroom supports her autonomy and comfort while allowing bladder emptying, which can facilitate labor progression. Encouraging regular voiding prevents bladder distension that could impede fetal descent. D. Check perineum for changes in "show" or discharge: Observing for changes in vaginal discharge is part of labor assessment but is not the immediate priority. The client’s request to void should be addressed first to ensure comfort and prevent complications.