A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. which of the following actions should the nurse make?

Question: A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. which of the following actions should the nurse make?

In the transition phase of labor, when a client reports the sensation of needing to have a bowel movement with the peak of contractions, it is a common sign that the baby is descending and labor is progressing. The nurse should first inform the patient about the progress of her labor and reassure her that this sensation is normal. It is essential to assist the patient with pant-blow breathing techniques to manage discomfort and avoid pushing before full dilation. Monitoring maternal vital signs and fetal heart rate is crucial and should be done every 30 minutes to an hour, or as ordered by the physician. Additionally, the nurse should continue contraction monitoring. If perineal bulging is noticeable, the nurse should prepare for delivery, ensuring all necessary equipment and personnel are ready. Providing emotional support and clear information during this intense stage of labor is also a key aspect of nursing care. Comfort measures, such as position changes, warm showers, or the use of a birthing ball, can be beneficial in alleviating discomfort.

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