Author Question: The labor and delivery nurse is reviewing charts. Of which client should the nurse inform the ... (Read 109 times)

PhilipSeeMore · **on:** Jun 28, 2018

The labor and delivery nurse is reviewing charts. Of which client should the nurse inform the supervisor?

1. Multip at 5 cm requesting labor epidural analgesia
2. Primip whose cervix remains at 6 cm for four hours
3. Multip who has developed nausea and vomiting
4. Primip requesting her partner to stay with her

Question 2

The pregnant client has completed the prenatal questionnaire, and asks the nurse why this form had to be completed. The best response by the nurse is:

1. Some people have things that have happened in the past that could impact their current pregnancy.
2. The doctor wants all of the pregnant clients to complete the form so that our records are complete.
3. We occasionally identify a health problem that puts the current pregnancy at higher risk.
4. This form is designed to predict who will develop problems with their pregnancy or delivery.

cpetit11 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

2
Rationale:
1. Contacting the supervisor is required when an abnormal situation is present. A multip requesting an epidural at 5 cm is not abnormal.
2. Average cervical change among primips in the active phase of the first stage of labor is 1.2 cm/hour; thus this client's lack of cervical change is unexpected, and should be reported to the supervisor.
3. Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation is present.
4. Clients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present.

Answer to Question 2

3
Rationale:
1. Although this is true, this statement is too vague to be the best response. It is best to explain specifically that the impact on the current pregnancy might put the pregnancy at higher risk.
2. The purpose of the form is to identify which clients have risk factors; the fact that records are complete is less important than identifying at risk pregnancies.
3. This is the reason for risk assessment during pregnancy, whether it is a patient-completed questionnaire or a nurse assessment form.
4. The form will identify those clients who have risk factors based on their medical history; prediction implies seeing into the future without a basis for the concern.