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Chapter 21: Problem 128

The client is found to be at +4 station. Which action is most appropriate for the nurse to take? ? A. Prepare for delivery ? B. Chart the finding ? C. Administer pain medication ? D. Increase the pitocin (oxytocin)

Short Answer

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Answer: The most appropriate action for a nurse to take when a client is at the +4 station during labor is to prepare for delivery. This is because the mother is in the advanced stage of labor and delivery is imminent. Preparing for delivery includes making sure all necessary equipment and the delivery room are ready. Other priorities such as charting the finding, pain management, and adjusting medical interventions can be addressed after the delivery.

Step by step solution

01

Understand the +4 station during labor

During labor, the level of the baby's head in relation to the mother's pelvis is measured using what's called stations. A +4 station means that the baby's head is well-engaged in the pelvis and is very close to being delivered. This indicates that the mother is in the advanced stage of labor.
02

Evaluate option A - Prepare for delivery

Considering that the client is at the +4 station, it is a strong indication that delivery is imminent. Therefore, preparing for delivery is a crucial part of the nurse's role at this stage. This includes making sure all necessary equipment and the delivery room are ready.
03

Evaluate option B - Chart the finding

Charting is essential for keeping an accurate record of the client's labor progress. However, since the client is at the +4 station, which means the delivery is imminent, simply charting the finding is not the most appropriate action. It can be done after taking care of the immediate priorities.
04

Evaluate option C - Administer pain medication

Pain management is essential for ensuring the client's comfort during labor. However, at the +4 station, administering pain medication may be too late. The focus should be on preparing and assisting the client during delivery.
05

Evaluate option D - Increase the pitocin (oxytocin)

Pitocin (oxytocin) is a medication used to induce or strengthen contractions during labor. Since the client is already at the +4 station, there is no need to increase the pitocin to further induce or strengthen contractions.
06

Determine the most appropriate action

Based on the evaluation of each option, the most appropriate action for the nurse to take when the client is at the +4 station is: A. Prepare for delivery - Because the mother is in the advanced stage of labor and delivery is imminent. This is the priority at this stage, and the other options can be taken care of after the birth.

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