QUESTION: "While the client is in active labor with twins and the cervix is 5 cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action?"
CHOICES
( X ) a.) Note the fetal heart rate patterns.
( O ) b.) Notify the physician immediately.
( X ) c.) Administer oxygen at 6 liters by mask.
( X ) d.) Have the client pant:blow during the contractions.
RATIONALE: The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation, unless cephalopelvic disproportion exists. The heart rates of both fetuses are being monitored continuously so noting the fetal heart rate patterns is already being accomplished. There is no indication that oxygen is necessary. Variable decelerations or decreased fetal heart rate indicate the need for oxygen. Having the client pant:blow may be done in the second stage of labor when she is pushing. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
