A client is admitted to the birth setting in early labor. She is ...

[jho37]

A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations.
 
  What would the nurse's initial response be? 1. Perform a vaginal exam
  2. Notify the physician
  3. Place the client in a left lateral position
  4. Administer oxygen at 2 L per nasal cannula

Question 2

The nurse in the OB-GYN clinic is working with a patient who is seeking her initial prenatal visit.
 
  The nurse will use the acronym TPAL to document the patient's number of: Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Term infants born.
  2. Children living in the home.
  3. Pregnancies ending in abortion.
  4. Preterm infants born.
  5. Pregnancies that occurred.

[AmberC1996]

Answer to Question 1

1
Explanation: 1. Prolapsed umbilical cord can occur when the membranes rupture. The fetus is more likely to experience variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord. A vaginal exam is the best way to confirm.

Answer to Question 2

1,3,4
Rationale 1: null
Rationale 2: L: number of currently living children to whom the woman has given birth, not the number in the home
Rationale 3: A: number of pregnancies ending in either spontaneous or therapeutic abortion
Rationale 4: null
Rationale 5: The documentation will not be of just any pregnancy, but descriptive of that pregnancy.

[jho37]

Excellent

[cpetit11]

TYSM