Author Question: A nurse is assisting with a forceps delivery. After the forceps are applied, the nurse notes fetal ... (Read 51 times)

dmcintosh · **on:** Jun 28, 2018

A nurse is assisting with a forceps delivery. After the forceps are applied, the nurse notes fetal bradycardia. What action by the nurse takes priority?

A.
Assess the fetal heart rate in 5 minutes.
B.
Document the findings in the chart.
C.
Inform the health-care provider immediately.
D.
Turn the woman on her left side.

Question 2

A new nurse is working with a patient undergoing an induction of labor. What action by the new nurse would prompt the preceptor to intervene?

A.
Assesses contractions every 5 minutes in the second stage of labor
B.
Calculates and charts the maternal total urine output every 4 hours
C.
Documents an IV intake of 1,500 mL in 8 hours
D.
Records the maternal vital signs a minimum of every 60 minutes

wtf444 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
When the forceps are applied, umbilical cord compression can occur. Compression of the cord causes a decrease in the fetal heart rate. The nurse should immediately inform the provider so that the pressure can be released. The nurse is responsible for documenting the fetal heart rate before and immediately after forceps application, but relieving the pressure on the umbilical cord takes priority. The nurse should not wait 5 minutes for another assessment, nor should the nurse turn the patient on her side as a first action.

Answer to Question 2

ANS: C
During an induction of labor, the IV fluid intake should not exceed 1,000 mL in 8 hours to prevent fluid overload after the placenta is delivered. If the new nurse has documented a larger amount, the preceptor needs to intervene. The other options show proper care of this patient.