A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
Methylergonovine 0.2 mg IM now.
Insert an indwelling urinary catheter.
Obtain laboratory study of prothrombin and partial thromboplastin time.
Administer oxygen by nonrebreather mask at 5 L/min.
The Correct Answer is A
Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.
Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.
Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.
Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.
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Correct Answer is D
Explanation
Choice A reason:
Administering oxygen via face mask is a common intervention for late decelerations; however, it is not the first-line action. Oxygen is given to improve fetal oxygenation, but repositioning the mother has a more immediate effect on improving uteroplacental blood flow and, consequently, fetal oxygenation12.
Choice B reason:
Increasing the infusion rate of IV fluid is an intervention used to expand maternal blood volume, which can improve placental perfusion. However, this is not the primary action to be taken when late decelerations are noted, as it may take time for the increased fluid to affect the uteroplacental circulation.
Choice C reason:
Elevating the client’s legs can help increase venous return to the heart, potentially improving uteroplacental circulation. Nonetheless, this is not the most immediate action to take for late decelerations, as it does not directly address the potential compression of the vena cava or aorta.
Choice D reason:
Positioning the client on her side, particularly the left side, is the priority nursing action for late decelerations. This position helps relieve pressure on the inferior vena cava, enhancing maternal cardiac output and increasing blood flow to the placenta, which can quickly improve fetal oxygenation and resolve late decelerations
Correct Answer is A
Explanation
Choice A reason:
Encouraging the client to empty her bladder every 2 hours is important because a full bladder can impede the progress of labor and increase the risk of bladder distension, which can lead to postpartum urinary retention or bladder atony. Additionally, a full bladder can obstruct the descent of the fetus and may contribute to labor dystocia. The normal range for urination frequency is typically every 3 to 4 hours, but during labor, more frequent emptying is beneficial.
Choice B reason:
While it may seem intuitive to remind the client to bear down with each contraction to aid in the delivery process, this is not recommended during the active phase of the first stage of labor. Bearing down, or pushing, is generally reserved for the second stage of labor when the cervix is fully dilated. Premature bearing down can lead to maternal exhaustion and increase the risk of cervical edema or lacerations.
Choice C reason:
Maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor. This position is typically used during the delivery process in the second stage of labor. During the active phase, the client should be encouraged to find a comfortable position that facilitates labor progress, such as walking, squatting, or using a birthing ball.
Choice D reason:
Performing vaginal examinations frequently is not advised because it can increase the risk of introducing infections and can be uncomfortable for the client. Vaginal examinations should be performed judiciously to assess labor progress, typically not more than every 4 hours unless there is a specific indication to do so.
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