A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Choice A rationale:

Vaginal hematoma is not a common complication in the 4th stage of labor. This stage primarily involves the recovery and stabilization of the mother after delivery.

Choice B rationale:

Hypoglycemia is not a typical complication in the 4th stage of labor. While blood glucose levels might be monitored during labor, the risk of hypoglycemia is generally higher in neonates, especially if the mother has diabetes.

Choice C rationale:

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, typically diagnosed during labor or shortly after delivery. It is not specific to the 4th stage of labor.

Choice D rationale:

Uterine hemorrhage is the most significant concern during the 4th stage of labor, also known as the "postpartum”. or "recovery”. stage. It refers to excessive bleeding from the site where the placenta detached. This bleeding can be life-threatening if not managed promptly.

Choice E rationale:

Dehiscence is the separation of surgical incisions, which is not a common complication during the 4th stage of labor.

The correct answer is choice B: “You must be feeling very scared.” This response is an example of therapeutic communication, where the nurse acknowledges the client’s feelings and provides emotional support without making assumptions or giving false reassurances.

Choice A rationale: While it’s true that the presence of a neonatal unit equipped to handle emergencies is reassuring, this response does not address the client’s immediate emotional needs or fears. It’s important for the nurse to recognize and validate the client’s feelings rather than focusing solely on the facilities available.

Choice B rationale: This choice demonstrates empathy and understanding. It allows the client to express their feelings and concerns, which is a crucial aspect of providing emotional support during labor. By acknowledging the client’s potential fear, the nurse opens the door for further communication and support.

Choice C rationale: This response minimizes the client’s individual feelings by suggesting that everyone has the same worries. It can make the client feel that their concerns are not unique or taken seriously, which is not conducive to establishing trust or providing individualized care.

Choice D rationale: This choice provides false reassurance. At 32 weeks of gestation, while the prognosis for the baby is generally good, there are still risks associated with preterm birth. It’s important not to make definitive statements about outcomes that cannot be guaranteed.