PNE 136/Maternity/PrepU 10
A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement? "Anxiety can speed up the labor process." "Anxiety can slow down the labor process." "Continuous labor support can result in better labor outcomes." "Nurses can influence birth outcomes in a positive way."
"Anxiety can speed up the labor process." Explanation: Anxiety causes the release of catecholamines, which slow down the labor process. Current research demonstrates that continuous labor support by a caring nurse results in better birth outcomes. Nurses can provide supportive care during labor and can influence birth outcomes in a positive way.
At what time is the laboring client encouraged to push? When the nurse wants the client to push When the fetal head can be seen When the cervix is fully dilated When the health care provider has arrived
When the cervix is fully dilated Explanation: To avoid birth trauma, the client is not encouraged to push until the cervix is fully dilated. This is determined on vaginal exam. Once it is noted, there is no need to wait until the fetal head can be seen. The urge to push may be present without full cervix dilation. Labor is not stopped until the health care provider arrives. A nurse can deliver the fetus.
Which protective equipment is most appropriate when assisting the health care provider in the delivery of the fetus? Select all that apply. Hair net Goggles Gown Gloves Face mask
Goggles Gloves Gown Explanation: The risk for splashing of body fluids is high during the delivery. Goggles or eye shields, a gown and gloves are necessary for protection. The hair net and face mask are seen in surgical areas.
In the labor and delivery unit, which is the best way to prevent the spread of infection? Complete hand hygiene Provide clean gloves in the room Use sterile gloves Limit vaginal examinations
Complete hand hygiene Explanation: Hand hygiene remains the best way to prevent the spread of infection. It is appropriate to use sterile gloves for invasive procedures and limit vaginal examinations as much as possible. Providing clean gloves is also important when there is exposure to blood and body secretions.
The client is now in the active phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the the client's breathing pattern to be effective, what outcome does the nurse expect? pants through each contraction as the client pushes uses accelerated breathing patterns continuously does not hyperventilate refrains from using the pant-blow technique so the client does nolt push
does not hyperventilate Explanation: The nurse will expect the client's breathing pattern to be effective, which mean the client will accelerated breathing techniques during contractions, does not hyperventilate, and uses pant-blow techniques to refrain from pushing despite pressure from the fetal head.
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 5 minutes every 15 minutes every 10 minutes every 20 minutes
every 15 minutes Explanation: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.
As a woman enters the second stage of labor, which would the nurse expect to assess? falling asleep from exhaustion reports of feeling hungry and unsatisfied feelings of being frightened by the change in contractions expressions of satisfaction with her labor progress
feelings of being frightened by the change in contractions Explanation: The nature of contractions changes so drastically— the urge to push is very strong—that this can be frightening.
A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her? Avoid flexing her knees so her abdomen is not tense. Avoid using her call bell to reduce interference. Lie supine so the tracing does not show a shadow. Lie on her side so she is comfortable.
Lie on her side so she is comfortable. Explanation: The best position for all women during labor is on their side.
Which intervention would be least effective in caring for a clinet who is in the active phase of labor? urging the client to focus on one contraction at a time providing one-to-one support having the client breathe with contractions encouraging the client to ambulate
encouraging the client to ambulate Explanation: Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, the client should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the client cope with the events of this phase, as well as help the client maintain a sense of control over the situation.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a shallow deceleration occurring with the beginning of contractions variable decelerations, too unpredictable to count fetal heart rate declining late with contractions and remaining depressed fetal baseline rate increasing at least 5 mm Hg with contractions
fetal heart rate declining late with contractions and remaining depressed Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.
A nurse is caring for a 16-year-old primigravida client who is in active labor. The client did not attend prenatal classes and nervously asks the nurse to explain to what will happen. The nurse performs a focused assessment to determine the stage of labor and then explains the different phases of the first stage of labor. The nurse determines client understanding when they correctly identifies how each phase differs. For each finding, click to specify if the finding indicates a latent or active phase of the first stage of labor. start of fetal descent complete dilation and effacement rapid dilation and effacement contractions 5 to 30 minutes apart contractions irregular, mild to moderate contraction duration 30 to 45 seconds contractions 2 to 3 minutes apart, strong to very strong cervical dilation 4 to 7 cm contraction duration 45 to 90 seconds
Active Phase: contractions 2 to 3 minutes apart, strong to very strong rapid dilation and effacement contraction duration 45 to 90 seconds start of fetal descent complete dilation and effacement cervical dilation 4 to 7 cm Explanation: A pregnant client will progress through two phases during the first stage of labor: latent and active. The first phase of the first stage of labor is the latent phase, where the client is talkative. In this phase, contractions are irregular and mild to moderate, 5 to 30 minutes apart, and last 30 to 45 seconds. The second phase of the first stage labor is the active phase. In the beginning of this phase, contractions become more regular and moderate to strong, occur every 3 to 5 minutes, and last 40 to 70 seconds. There is also rapid cervical dilation 4 to 7 cm, and the fetus starts to descend. In the end of the active phase of the first stage of labor, the contractions become strong and occur 2 to 3 minutes apart, and last 45 to 90 seconds. At the end, complete cervical dilation at 10 cm with full effacement occurs.
The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? palpate for bladder fullness do nothing, this is benign notify the health care provider reposition the client on either side
reposition the client on either side Explanation: Deceleration may be related to compression on the maternal abdominal aorta and inferior vena cava and repositioning the woman to either her right or left side will remove the pressure and allow the blood flow to resume. If this is not effective then the nurse would look for other potential causes such as an infusion of oxytocics. If this is unsuccessful the RN and health care provider needs to be notified immediately. The fetus is not getting enough oxygen and needs intervention. Palpating for bladder fullness would not be appropriate at this time. This is a serious situation developing and needs prompt intervention.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Assess fetal heart rate for fetal safety. Test a sample of amniotic fluid for protein. Elevate her hips to prevent cord prolapse. Ask her to bear down with the next contraction.
Assess fetal heart rate for fetal safety. Explanation: Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.
A client who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed? preeclampsia placenta previa premature labor multiple births
placenta previa Explanation: Vaginal examinations should never be done if the woman presents with bright red painless bleeding until placenta previa is ruled out. The other options would not be concerns at this time based on the findings.
The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? "The client states that she is having heavy bleeding." "The client has lost 100cc of blood from what I approximate on her clothing." "When ambulating the client to the bathroom, a gush of red blood was noted." "The client has saturated three sanitary napkins in the past 4 hours."
"The client has saturated three sanitary napkins in the past 4 hours." Explanation: The best way to determine and report the amount of bleeding is by the number of sanitary napkins that have been saturated. This provides a common and measurable way to determine the approximate amount of bleeding. Stating heavy bleeding or a gush of blood is subjective. Determining the amount of bleeding from assessing stained clothing is difficult.
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? Notify the registered nurse. Notify the health care provider. Wait 2 minutes to review another tracing. Assess and reposition the woman.
Assess and reposition the woman. Explanation: Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.
A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? Notify the health care provider about possible meconium. Check the pH to ensure the fluid is amniotic fluid. Check the maternal heart rate. Prepare to administer an antibiotic.
Notify the health care provider about possible meconium. Explanation: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.
At which time does the nurse anticipate that the primigravid client, G1P0, will need the most pain relief measures? active phase (late) of the first stage of labor pelvic phase (early) of the second stage of labor latent phase (early) of the first stage of labor perineal phase (late) of the second stage of labor
active phase (late) of the first stage of labor Explanation: For a client experiencing their first labor (primigravid), the most pain medication is given during the active phase of the first stage of labor. Implementing general comfort measures with opioid analgesia or epidural anesthesia is common. The latent phase is the early portion of labor. This is frequently completed at home with comfort measures provided by the support person. The second stage of labor begins with the pelvic stage and ends with the perineal phase and birth. During this stage, opioid pain medication is contraindicated, due to its effects on the fetus.
Which action is a priority when caring for a client during the fourth stage of labor? assisting with perineal care encouraging the client to void offering fluids as indicated assessing the uterine fundus
assessing the uterine fundus Explanation: During the fourth stage of labor, a priority is to assess the client's fundus to identify risk for postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.
A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: olive green. pink. blue. yellow.
blue. Explanation: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? a neonatologist to insert the electrode floating presenting fetal part cervical dilation (dilatation) of 2 cm or more intact membranes
cervical dilation (dilatation) of 2 cm or more Explanation: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation (dilatation) of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.
A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? uterus becoming discoid shaped shortening of the umbilical cord boggy, soft uterus sudden gush of dark blood from the vagina
sudden gush of dark blood from the vagina Explanation: Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.
At which time is it most important to monitor for umbilical cord prolapse? At the onset of labor After rupture of membranes During transitional labor When the fetus is crowning
After rupture of membranes Explanation: The fetus is at highest risk for umbilical cord prolapse after the rupture of membranes. It is important to assess the fetal heart rate for one full minute. The other options are not as high of a risk.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Test a sample of amniotic fluid for protein. Assess fetal heart rate for fetal safety. Ask her to bear down with the next contraction. Elevate her hips to prevent cord prolapse.
Assess fetal heart rate for fetal safety. Explanation: Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Ask her to pant with the next contraction. Administer oxygen at 3 to 4 L by nasal cannula. Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side.
Turn her or ask her to turn to her side. Explanation: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
Which method does the nurse use to determine fetal presentation, position, and attitude? Complete a vaginal examination. View on an ultrasound. Assess location of fetal kicks. Utilize Leopold maneuvers.
Utilize Leopold maneuvers. Explanation: Leopold maneuvers are a noninvasive method of assessing fetal presentation, position, and attitude by placing hands on the maternal abdomen and locating fetal body parts. Ultrasounds are not done by nurses and not typically done at this stage of pregnancy. Assessing fetal kicks and conducting a vaginal examination will not provide accurate data.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? variable decelerations, too unpredictable to count a shallow deceleration occurring with the beginning of contractions fetal heart rate declining late with contractions and remaining depressed fetal baseline rate increasing at least 5 mm Hg with contractions
fetal heart rate declining late with contractions and remaining depressed Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.
A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply. activity of fetus status of membranes frequency intensity duration
frequency duration intensity Explanation: When assessing a woman's contraction pattern, it is important to include frequency, duration, and intensity. Although knowing the status of the membranes and activity of the fetus are both important, they are not part of the contraction pattern.
As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding? providing pain relief for the mother koala care making sure the significant other holds the infant shortly after birth kangaroo care
kangaroo care Explanation: If the woman permits it, place the newborn skin-to-skin against her body and place several blankets over them. This technique (called kangaroo care) keeps the infant warm and promotes bonding.
A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? Perform a vaginal exam. Check the fetal heart rate. Change the linen saver pad. Notify the primary care provider immediately.
Check the fetal heart rate. Explanation: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.
A client is admitted to the labor and delivery unit. Upon examination, the client is found to be dilated 3 cm. The nurse notes that the client is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this client? active phase pelvic phase perineal phase latent phase
latent phase Explanation: Contractions during the latent phase of labor are typically 5 to 10 minutes apart and last 30 to 45 seconds. The cervix is dilated 1 to 6 cm, and effacement is 0% to 40%. During the active phase of labor, contractions are typically 2 to 5 minutes apart and last 46 to 60 seconds. The cervix is dilated 6 to 10 cm, and effacement is 40% to 100%. During the pelvic phase of labor, the fetus descends into the birth canal. During the perineal phase of labor, contractions are typically 2 to 3 minutes apart and last 60 to 90 seconds.
A client is admitted to the labor and delivery unit. Upon examination, the client is found to be dilated 3 cm. The nurse notes that the client is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this client? perineal phase active phase latent phase pelvic phase
latent phase Explanation: Contractions during the latent phase of labor are typically 5 to 10 minutes apart and last 30 to 45 seconds. The cervix is dilated 1 to 6 cm, and effacement is 0% to 40%. During the active phase of labor, contractions are typically 2 to 5 minutes apart and last 46 to 60 seconds. The cervix is dilated 6 to 10 cm, and effacement is 40% to 100%. During the pelvic phase of labor, the fetus descends into the birth canal. During the perineal phase of labor, contractions are typically 2 to 3 minutes apart and last 60 to 90 seconds.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? variable decelerations early decelerations accelerations prolonged decelerations
prolonged decelerations Explanation: Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.
A client in labor received an opioid close to the time of birth. At the time of the birth, the nurse will assess for which effect? urinary retention in the pregnant client abdominal distention in the pregnant client respiratory depression in the newborn hyperreflexia
respiratory depression in the newborn Explanation: Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the client who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia is more commonly associated with central nervous system depression due to opioids.
A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 beats/min The nurse is aware that which factors can result in fetal tachycardia? Select all that apply. uteroplacental insufficiency fetal movement maternal fever fetal distress opioid medication to maternal client
uteroplacental insufficiency fetal movement maternal fever fetal distress Explanation: An increase in the FHR (tachycardia) from the baseline can mean that there is fetal movement or some type of fetal distress related to a maternal fever or fetal hypoxia which can be the result of uteroplacental insufficiency. Opioids would lead to fetal bradycardia.
Which nursing action is applied throughout all stages of labor? Place the client on nothing by mouth (NPO) status while in labor. Discourage the client from ambulating after the rupture of membranes. Do not allow the client to lay flat on her back for long periods. Limit the client to have no more than one support person in the labor room.
Do not allow the client to lay flat on her back for long periods. Explanation: Throughout the labor process, the client is not to lay flat on her back due to supine hypotension. This places weight on the great vessels and decreases blood flow. It is acceptable to place a pillow or wedge under one hip, thus distributing the client's weight to one side. The client may do the other options at different points throughout the labor process.
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Help the woman change positions. Document the finding. Prepare the woman for an emergency cesarean birth. Obtain assistance to check for a compressed umbilical cord.
Help the woman change positions. Explanation: First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? Rubbing the client's legs Providing a paper bag Placing a wedge under the hips Massaging the client's lower back
Placing a wedge under the hips Explanation: Due to the lithotomy position, the nursing action of placing a wedge under the hips is correct to avoid supine hypotension. Rubbing the legs or massaging the back can relax the client between intense contractions but those actions do not prevent a complication. Providing a paper bag prevents hyperventilation typically caused by pattern breathing.
The client may spend the latent phase of the first stage of labor at home unless which occurs? The contractions vary in length and intensity The client passes the bloody show The client experiences a rupture of membranes The client begins back labor
The client experiences a rupture of membranes Explanation: Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place? The uterus contracts and squeezes the cord against the fetus. fetal sleep prematurity The uterus relaxes between contractions.
The uterus contracts and squeezes the cord against the fetus. Explanation: Cord compression is not continuous when variable decelerations are occurring. The compression occurs when the uterus contracts and squeezes the cord against the fetus. It is relieved when the uterus relaxes between contractions. Prematurity and fetal sleep will cause decreased or absent variability.
A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes? a positive bacterial culture a positive nitrazine test leakage from the perineum when the client coughs greenish fluid noted on the client's underwear
a positive nitrazine test Explanation: A confirmation that the client has a rupture of membranes includes a positive nitrazine test. A positive test is when the nitrazine paper turns a dark blue indicating that the fluid is alkaline. Urine also leaks when a client coughs. Greenish fluid on the underwear is not confirmation of the rupture of membranes. A positive bacterial culture is not indicative of the rupture of membranes.
The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? an ultrasound to determine fetal age a urine culture to rule out a urinary tract infection a blood culture to note any infection of the blood a urine dipstick test to check for protein
a urine dipstick test to check for protein Explanation: Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point.
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: baseline variability. fetal bradycardia. baseline FHR. short-term variability.
baseline FHR. Explanation: The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.
Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide? "It is important to try to urinate every 2 hours because you might not feel the urge." "Even though you are sweating, you still need to urinate at least every hour." "You need to get up and walk around a bit so that your bladder can get filled more fully," "You need to give a urine specimen each time you urinate so we can check for infection."
"It is important to try to urinate every 2 hours because you might not feel the urge." Explanation: During labor, pressure from the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Therefore, it is important to have the pregnant client void approximately every 2 hours during labor to avoid overfilling, because overfilling can decrease postpartum bladder tone. Bladder filling is not affected, and there is no need to give a urine specimen with each voiding. Insensible fluid loss does occur with sweating, but is not associated with the need for voiding every 2 hours.
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? 10:30 a.m. 11:15 a.m. 10:05 a.m. 11:30 a.m.
10:30 a.m. Explanation: Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives opioids or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.
A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response? A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. Explain that you will have to call the physician and get an order to leave the fetal monitor off. Insist that the fetal monitor be used due to a lack of staff to adequately monitor her using any other method. Tell her that it is her decision, but that she will be placing herself and her baby at grave risk.
A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently. Explanation: An acceptable method for monitoring fetal heart rate (FHR) in a low-risk pregnancy is to use intermittent auscultation (IA). The most common practice is to place the woman on an external fetal monitor for 20 minutes to get a baseline evaluation of the FHR. If the pattern is reassuring, then a fetoscope, handheld Doppler device, or the external fetal monitor is used to monitor the FHR at intermittent intervals. The nurse should never threaten the client or make her feel guilty about not using the equipment due to any reason, including lack of staff or claiming she is endangering her baby by not using it. The order should already be written to allow the client the option of not using the monitor based on certain parameters of the fetal monitor reading.
