QUESTION: "A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. Which of the following would the nurse need to assess first after admission to the birthing area?"
CHOICES
( X ) a.) Time of last food and fluid intake.
( X ) b.) Fetal position and station.
( O ) c.) Contraction frequency and intensity.
( X ) d.) Ability to follow directions.
RATIONALE: When admitting a multigravid client to the birthing area, the nurse needs to obtain information about the frequency, intensity, and duration of labor contractions, the time when the labor began, whether the membranes have ruptured, and the client's estimated delivery date. From this information, the nurse gets a quick overview of the client's status and can then proceed to plan effective care. Although the time when the client last had food or fluids is important, this information can be obtained later because it is less influential in determining the initial plans for care. Although information about the fetal position is important, this information is less influential in determining the initial plans for care. The client's ability to follow directions is important but this information can be obtained later because it plays a less influential role in initial plans for care. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
