[Expert Solution]: A nurse is caring for a client in active labor

A nurse is caring for a client in active labor. Admission Assessment. 0200:. Gravida 1, Para 0 at 39 weeks gestation. Presents with. contractions occurring every 5 to 6 min, 45 to 60 seconds. duration. Cervical examination 4 cm dilated, 50% effaced. Admit. to the labor and delivery unit. Nurses’ Notes. 0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale. of O to 10 with contractions. Cervix 4 cm dilated, 50% effaced, with membranes intact. 0230:. The client reports increasing discomfort with contractions. Cervix 5. cm dilated, 60% effaced, with membranes intact. Contractions. occurring every 5 min, 45 to 60 seconds duration. 0300:. Epidural anesthesia was initiated. Cervix 7 cm dilated, 70% effaced,. with membranes intact. Contractions occur every 4 to 5 min, 60 seconds duration. Vital Signs. 0200:. Temperature 36.9deg C (98.4deg F). Heart rate 86/min. Respiratory rate 18/min. BP 118/78 mm Hg. 0230:. Temperature 37deg C (98.6deg F). Heart rate 88/min. Respiratory rate 20/min. BP 120/80 mm Hg. 0300:. Temperature 37.1deg C (98.8deg F). Heart rate 90/min. Respiratory rate 18/min. BP 122/76 mm Hg. The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential. contraindicated for the client. A. Assess for urinary retention. B. Encourage the client to turn from side to side. C. Monitor for elevated temperature. D. Inform the client to expect drowsiness. E. Assist the client with ambulation.