Answer to Question 1
4: During activity, stop for fluids every 1520 minutes.
Rationale:
During activity, stopping for fluids every 1520 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.
Answer to Question 2
1. Multipara at 7 cm, fetal heart tones auscultated every 90 minutes
Rationale:
During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is too infrequent. This is the client that should receive further intervention first. External monitoring can be used instead of auscultation of the fetal heart tones during labor for the primipara at 10 cm and pushing. Meconium-stained amniotic fluid is not an expected finding; however, internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. This client is being treated appropriately and would not need intervention first. External monitoring during preterm labor will assess both contractions and fetal status, so the primipara in preterm labor will not be the priority for intervention. .
A nurse communicates with her non–English-speaking patient through an interpreter
Nurse collaboration
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Patient teaching: heart assessment
Patient teaching: female breast assessment
Patient Teaching Methods Cont.