Maternity Nursing: Intrapartum Q 7
A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority?
A. Keeping the significant other informed of the progress of the labor.
B. Providing comfort measures.
C. Monitoring fetal heart rate.
D. Changing the client’s position frequently.
Correct Answer: C. Monitoring fetal heart rate.
The priority is to monitor the fetal heart rate. The continuous monitoring of the external fetal heart rate provides insight into fetal well-being. The assessment of the fetal heart rate could be performed utilizing external or internal fetal heart rate monitoring. An alternative is fetal heart rate auscultation every 15 minutes in the first stage of labor and after each contraction during the second stage of labor. In the interpretation of the fetal heart rate strip millimeters considered are baseline viability, basal heart rate, cardiac accelerations or decelerations, endocrine activity. Strip abnormalities are characterized based on consideration of the above parameters.
Option A: At admission to labor and delivery, prenatal records and obstetric history should be reviewed because these optimally inform the provider to the best intrapartum obstetric care. This care includes the determination of the static gestational age.
Option B: Most labor and delivery units will have an established protocol for administration of oxytocin that entails the administration of the proper medication and dosage, as well as criteria for an incremental increase as clinically warranted. The protocols also include monitoring maternal and fetal vital signs, as well as the atria, for discontinuation of the medication in the event of concern for tachycardia systole all fetal well-being.
Option D: The uterine activity is assessed by external tocometry and targeted at 3 to 5 contractions in the 10-minute window. The contractions should last 30 to 40 seconds to be effective. Internal intrauterine pressure assessment using a catheter could be utilized, in which case marked medial units are used and targeted at more than 200 Montevideo units in a 10-minute window. The monitoring of uterine contractions should be continuous during labor.