Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:

Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:

• A. Assess the cervical dilation and station
• B. Administer an antiemetic
• C. Check the fetal heart rate
• D. Check the mother's vital signs

Answer: (A)

In active labor, the most important information to guide immediate management is how the cervix and presenting part are changing. A vaginal examination to reassess cervical dilation and the station quickly shows whether labor is progressing or if there might be arrest or distress requiring intervention. If the dilation has advanced beyond 5 cm and the head has descended (or at least remains on track with descent), this supports ongoing, normal labor and informs subsequent steps. If there’s no change over a period, you’d consider augmentation or planning delivery. The symptoms described—nausea, a slight chill with perspiration, and irritability—can occur with labor pain and autonomic responses but don’t by themselves indicate the next needed action without knowing the current progression of labor. Therefore, the first action is to determine where the cervix and fetal presenting part are now, which directs the rest of the assessment and care (including fetal tracing and maternal vitals) accordingly.

In active labor, the most important information to guide immediate management is how the cervix and presenting part are changing. A vaginal examination to reassess cervical dilation and the station quickly shows whether labor is progressing or if there might be arrest or distress requiring intervention.

If the dilation has advanced beyond 5 cm and the head has descended (or at least remains on track with descent), this supports ongoing, normal labor and informs subsequent steps. If there’s no change over a period, you’d consider augmentation or planning delivery. The symptoms described—nausea, a slight chill with perspiration, and irritability—can occur with labor pain and autonomic responses but don’t by themselves indicate the next needed action without knowing the current progression of labor. Therefore, the first action is to determine where the cervix and fetal presenting part are now, which directs the rest of the assessment and care (including fetal tracing and maternal vitals) accordingly.