Author Question: The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to ... (Read 22 times)

amal · **on:** Jun 28, 2018

The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80, and -2. An epidural was administered shortly thereafter.

Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90, and -2. What is the nurse's next action?

a. Palpate the patient's bladder for fullness.
b. Contact the health care provider for a prescription to augment the labor.
c. Obtain an order for an internal pressure catheter.
d. Reassure the patient that she is making adequate progress.

Question 2

Which assessment finding in the postpartum client following a uterine inversion indicates normovolemia?

a. Blood pressure of 100/60 mm Hg
b. Urine output >30 mL/hr
c. Rebound skin turgor <5 seconds
d. Pulse rate <120 beats>

T4T · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
The fetal presenting part is expected to descend at a minimal rate of 1 cm/hr in the nullipara and 2 cm/hr in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.

Answer to Question 2

ANS: B
In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hr; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats>