Question

The laboring client is experiencing contractions every \(2-3\) minutes lasting 90 seconds. The client's fetal heart rate is ranging from 130 to 140 beats per minute (BPM) with variability of \(6 \mathrm{p}-10\) beats per minute. Which action by the nurse is most appropriate? A. Discontinue the IV fluid containing Pitocin (oxytocin) B. Document the finding in the client's medical record C. Contact the doctor at once and reposition the client D. Insert an internal fetal scalp electrode monitor

Short answer

Answer: The most appropriate action for the nurse to take is to document the finding in the client's medical record.

Step-by-step solution

Analyze the given data

We are given the following information about the client: - Contractions every 2-3 minutes - Contractions lasting 90 seconds - Fetal heart rate (FHR) at 130-140 beats per minute (BPM) - Variability of 6-10 BPM

Evaluate the contractions

During labor, contractions are expected to occur at regular intervals and increase in intensity, frequency, and duration. In this case, contractions every 2-3 minutes lasting 90 seconds are normal for the active phase of labor.

Evaluate the fetal heart rate and variability

A normal FHR is between 110 and 160 BPM, so the client's FHR of 130-140 BPM falls within the normal range. FHR variability measures the fluctuations in FHR and is an important indicator of fetal well-being. Normal FHR variability is between 6 and 25 BPM; therefore, the given variability of 6-10 BPM is considered normal.

Assess the given actions and determine the most appropriate one

Review the potential actions and determine which one is the most appropriate: A. Discontinuing the IV fluid containing Pitocin (oxytocin) would not be appropriate, as the contractions and FHR are within normal limits, and there is no indication of fetal distress or hyperstimulation. B. Documenting the findings in the client's medical record is appropriate, as the contractions and FHR are within normal limits, and there are no issues to report. C. Contacting the doctor and repositioning the client would only be necessary if there were signs of fetal distress, which there are none. D. Inserting an internal fetal scalp electrode monitor is an invasive procedure and should only be done if there are concerns about the accuracy of external monitoring, which there are not in this case.

Choose the most appropriate action

Based on the analysis of the given data and actions, the most appropriate action for the nurse to take would be: B. Document the finding in the client's medical record.

Key concepts

Nursing Assessment

Nursing assessment is a critical process that involves the evaluation of a patient's physiological and psychological state. During labor, nurses must carry out comprehensive assessments to ensure the safety and well-being of both the mother and the baby. In the context of a laboring client, the assessment includes:

• Monitoring contractions, noting their frequency, duration, and intensity
• Evaluating the fetal heart rate (FHR) and variability
• Observing signs of maternal complications

By systematically gathering this information, nurses can detect any abnormalities or distress signals early. Effective nursing assessment lays the foundation for informed decision-making, ensuring timely interventions if necessary. It is the cornerstone of providing quality care during labor and delivery.

Fetal Heart Monitoring

Fetal heart monitoring is a vital tool used during labor to assess the well-being of the fetus. It involves tracking the fetal heart rate (FHR) for any irregularities or signs of stress. The normal range for FHR is between 110 and 160 beats per minute (BPM). Variability in FHR, which refers to fluctuations in the heart rate from one beat to the next, is also crucial. Normal variability ranges from 6 to 25 BPM, indicating a healthy, well-oxygenated baby. Key aspects of fetal heart monitoring during labor are:

• Continuous or intermittent tracking of FHR
• Identifying any decelerations or accelerations
• Detecting changes in variability

These elements help nurses identify any potential problems early, allowing for timely interventions to prevent fetal distress and ensure a safe delivery.

Labor and Delivery

Labor and delivery are significant, complex processes where the mother's body works to give birth to the baby. It involves several stages, each characterized by specific physiological changes. During the active phase of labor, contractions typically become more regular, occurring every 2-3 minutes and lasting between 60 and 90 seconds. These contractions work to dilate the cervix and move the baby through the birth canal. Key components of labor and delivery include:

• The onset of regular contractions
• Cervical effacement and dilation
• Descent and birth of the baby
• Delivery of the placenta

Understanding these stages helps nursing professionals provide effective support and interventions, ensuring safety for both the mother and the baby throughout the delivery process.

Nursing Interventions

Nursing interventions during labor and delivery are proactive actions taken by nurses to support and ensure the well-being of both mother and baby. These interventions are based on ongoing assessments and may vary depending on the labor's progression and any emerging complications. Common nursing interventions include:

• Positioning the mother for comfort and optimal fetal monitoring
• Administering medications as prescribed, such as pain relief or oxytocin
• Monitoring vital signs of both mother and baby
• Providing emotional support and education to the mother

Nurses play a crucial role in managing the labor process, as they are often the first to detect any complications and are responsible for implementing the appropriate interventions. This active involvement ensures a safe and positive birth experience for the patient.