A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor.

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A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor.

The nurse should instruct her:
A . To hold her breath during contractions
B . To be flat on her back
C . Not to push with her contractions
D . To push before becoming fully dilated

Answer: C

Explanation:

(A) This nursing action may cause hyperventilation.

(B) This nursing action could cause inferior vena cava syndrome.

(C) The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor.

(D) If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications.

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