Question

The nurse is assessing the client in the first stage of labor. The fetal heart tones are checked using a fetoscope and found to be 105–115 per minute, the contractions by palpation are every three minutes, and the client is complaining of extreme pain in the lower abdomen. Which action should the nurse take at this time? ? A. Document the finding ? B. Assess the fetal monitor strip ? C. Call the physician ? D. Prepare for delivery

Short answer

Answer: C. Call the physician

Step-by-step solution

Analyze the fetal heart tones

The fetal heart tones are given as 105-115 per minute. According to guidelines, a normal fetal heart rate (FHR) is between 110 and 160 beats per minute. Therefore, the FHR in this case is slightly lower than the normal range.

Analyze the contractions

The client's contractions are occurring every three minutes. During the first stage of labor, contractions typically last about 30 to 45 seconds and occur every 5 to 20 minutes. As they progress, contractions become more frequent and last longer. In this case, contractions are occurring more frequently than they would be at the beginning of the first stage of labor, suggesting the labor is progressing.

Analyze the pain level

The client is complaining of extreme pain in the lower abdomen, which is an expected symptom of labor. Pain in labor varies widely between individuals but, in general, the pain will increase as labor progresses.

Evaluate the answer choices

Now let's evaluate the answer choices based on the analysis: A. Document the finding - While it is important to document all findings, this should not be the only action taken by the nurse, given the situation. B. Assess the fetal monitor strip - This could be a reasonable option, but given that a fetoscope was already used to check the FHR and evaluate the situation, it is not the most appropriate action at this time. C. Call the physician - Since the FHR is slightly lower than normal and contractions are more frequent than expected at the beginning of the first stage of labor, it would be appropriate to call the physician to evaluate the situation and determine any necessary interventions. D. Prepare for delivery - While it's important to be ready for delivery, the client is still in the first stage of labor, and there may be some time before delivery is imminent. Additionally, given the FHR and contraction information, it is more appropriate to call the physician first to evaluate the situation. Based on our analysis, the most appropriate action for the nurse to take at this time is: ? C. Call the physician

Key concepts

Fetal Heart Tones Assessment

During pregnancy, the health of the fetus is closely monitored through various assessments, with the assessment of fetal heart tones being a critical component. This measurement reflects the well-being of the baby inside the womb. A normal range for fetal heart rate (FHR) typically falls between 110 and 160 beats per minute. Deviations from this range could indicate distress or developmental issues, requiring further evaluation by healthcare providers.

For a nursing professional studying for the NCLEX-PN, understanding how to properly assess fetal heart tones is essential. These heart tones are often first checked during prenatal visits using a Doppler ultrasound instrument and then during labor with either a Doppler device or fetoscope. It is important to recognize both the average FHR and the significance of variations from normal patterns. For instance, a slightly lower than normal FHR—as demonstrated in the exercise—may prompt a nurse to seek a physician's consult to evaluate fetal well-being.

In the real-life setting, nurses should not only rely on single readings but also consider patterns and changes over time. The presence of accelerations (temporary increases in the FHR) and decelerations (temporary decreases in the FHR) can provide additional data about the fetal state, especially in response to contractions.

Labor Contraction Frequency

Contraction frequency is an indication of how labor is progressing and is measured by how often contractions occur. Early labor is generally characterized by contractions that are mild in intensity and occur at longer intervals, about every 5 to 20 minutes. As labor advances, contractions increase in both frequency and intensity.

For students and practicing nurses, understanding and recognizing the frequency and progression of contractions are critical. It helps in determining the stage of labor and in making timely decisions for labor management. In the example provided, contractions every three minutes signify active labor, which might necessitate different interventions or monitoring compared to early labor. It's imperative to communicate clearly with other healthcare team members when there's a significant change in labor contraction frequency, as it can affect the care plan, including the decision whether to call the physician or prepare for delivery.

Recognizing signs of rapid progression, such as frequent contractions that may indicate advanced labor, can prevent complications and ensure the safety of both the mother and baby.

Labor Pain Management

Labor is often associated with significant pain for the delivering individual. Effective pain management is crucial for providing comfort and facilitating a successful delivery process. Pain can vary widely from one individual to another, and perceptions and tolerance of pain are highly subjective. In any labor scenario, from the one depicted in the exercise to those encountered in clinical practice, nurses must assess and manage labor pain appropriately.

In managing pain during labor, nurses have various non-pharmacological and pharmacological strategies at their disposal. Non-pharmacological approaches include breathing techniques, massage, warm baths, and position changes, while pharmacological options might involve analgesics and regional anesthesia such as epidurals. A key aspect of NCLEX-PN exam preparation is understanding these various pain management methodologies and their appropriate application.

Moreover, it is critical for nurses to continuously communicate with the laboring individual, assessing pain levels and providing reassurance. By administering pain relief measures based on the patient's specific needs and preferences, nurses play a pivotal role in the birthing process, ensuring patient-centered care that can significantly impact the entire labor experience.