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:

The presence of a “bloody show” from the vagina is a normal part of labor. It’s caused by the expulsion of the mucus plug that

has sealed the cervix during pregnancy. This is a common occurrence and does not need to be reported to the provider.

Choice B rationale:

Early decelerations in the Fetal Heart Rate (FHR) are usually not a cause for concern. They are often a sign of head

compression, which is a normal occurrence during labor. Therefore, this finding does not need to be reported to the provider.

Choice C rationale:

Uterine contractions lasting 2 minutes could be a sign of a complication known as “uterine tachysystole” or “hyperstimulation”. This condition can reduce oxygen supply to the baby and may require medical intervention. Therefore, this finding should be reported to the provider.

Choice D rationale:

Feeling pelvic pressure with contractions is a normal part of the second stage of labor. This pressure is due to the baby moving

down into the birth canal. Therefore, this finding does not need to be reported to the provider.

Choice A rationale:

Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.

Choice B rationale:

Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.

This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.

Choice C rationale:

While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that

can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural

instincts.

Choice D rationale:

Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary

strain and doesn’t take into account the individual rhythms and responses of the mother’s body.