A client in labor is requesting pain medication. The nurse ...

[RODY.ELKHALIL]

A client in labor is requesting pain medication. The nurse assesses her labor status first, focusing on which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
 
  1. Contraction pattern
  2. Amount of cervical dilatation
  3. When the labor began
  4. Whether the membranes are intact or ruptured
  5. Fetal presenting part

Question 2

During a maternal assessment, the nurse determines the fetus to be in a left occipitoanterior (LOA) position. Auscultation of the fetal heart rate should begin in the:
 
  1. Right upper quadrant.
  2. Left upper quadrant.
  3. Right lower quadrant.
  4. Left lower quadrant.

[memslove]

Answer to Question 1

1, 2, 5
Explanation: 1. The client should have a good contraction pattern before receiving an analgesic.
2. The nurse should evaluate the amount of cervical dilatation before analgesic medication is administered.
5. If normal parameters are absent or if nonreassuring maternal or fetal factors are present, the nurse may need to complete further assessments with the physician/CNM.

Answer to Question 2

4
Rationale 1: The fetus is head-down, so the heart rate will not be heard in an upper quadrant.
Rationale 2: The fetus is head-down, so the heart rate will not be heard in an upper quadrant.
Rationale 3: Due to the position of the fetus, the heart rate will not be heard on the right side.
Rationale 4: The fetal heart rate is best heard at the fetal back. In a cephalic presentation, the heart rate is heard in the lower quadrants. Because this fetus is on the mother's left side, the heart tones will be heard on the mother's left lower quadrant.

[RODY.ELKHALIL]

Excellent

[pangili4]

TYSM