The nurse is orienting a new graduate nurse to the labor and ...

[debasdf]

The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective?
 
  1. A vaginal examination is performed if delivery appears to be imminent.
  2. Her prenatal record is reviewed for indications of domestic abuse.
  3. She will be positioned supine to facilitate a normal blood pressure.
  4. A urine specimen is obtained by catheter to check for protein and ketones.

Question 2

A client's fetal heart rate tracing has a consistent late deceleration pattern. What actions should the nurse take at this time? Select all that apply.
 
  1. Prepare for cesarean birth.
  2. Increase intravenous fluids.
  3. Monitor maternal blood pressure.
  4. Position client on the left side.
  5. Apply oxygen 7 to 10 L via face mask.

[coyin]

Answer to Question 1

1
Explanation:
1. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal examination is performed after the vital signs are obtained.
2. Domestic abuse is not the sole reason the prenatal record is examined; any complications of pregnancy are noted.
3. Supine position predisposes the client to supine hypotension syndrome; side-lying is preferred.
4. A midstream clean-catch specimen is obtained to assess for proteinuria and ketonuria.

Answer to Question 2

3, 4, 5
Explanation:
1. Preparing for cesarean birth would be an action for late decelerations with tachycardia or decreasing variability.
2. Increasing intravenous fluids would be an action for late decelerations with tachycardia or decreasing variability.
3. Nursing actions for a late deceleration pattern include monitoring maternal blood pressure.
4. Nursing actions for a late deceleration pattern include positioning the client on the left side.
5. Nursing actions for a late deceleration pattern include applying oxygen 7 to 10 L via face mask.