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. While it is important to monitor fetal heart rate patterns, the immediate concern in this scenario is to address potential factors affecting the labor progress, such as bladder distention. B. Obtaining a straight catheter kit to empty the client's bladder may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first. C. Checking for changes in discharge can be part of labor assessment, but it does not directly address the client’s immediate request to empty her bladder and the unchanged cervical exam. D. If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.