The labor and delivery unit charge nurse has received a change-of-shift report on the following clients in labor.
Which client should the charge nurse ask the staff nurse to see first?
The labor and delivery unit charge nurse has received a change-of-shift report on the following clients in labor.
Which client should the charge nurse ask the staff nurse to see first?
A. A 28-year-old primigravida at 39 weeks gestation, currently in active labor, with a fetal heart rate of 90-100 bpm.
[75%]
B. A 35-year-old multipara at 41 weeks gestation, currently in early labor, with a history of rapid labor in her previous delivery.
[13%]
C. A 20-year-old multipara at 37 weeks gestation, currently in active labor, with a history of two previous cesarean deliveries.
[9%]
D. A 25-year-old multipara at 38 weeks gestation, currently in early labor, with cervical dilation of 3 cm.
[2%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Management of Care
Related Topic
Establishing Priorities
Item Type
Item Type
AnalyzeCues
Explanation
Choice A is correct. A normal fetal heart rate typically ranges between 110-160 bpm. A fetal heart rate of 90-100 bpm may indicate fetal distress or compromise and requires immediate assessment and intervention by a healthcare provider.
Choice B is incorrect. While this client has a history of rapid labor in a previous delivery, she is currently in early labor, which is generally a less urgent phase. Early labor allows ample time for monitoring and assessment before the active phase begins.
Choice C is incorrect. This client's history of two previous cesarean deliveries is significant and requires careful monitoring during labor. There are no indications of complications or distress mentioned in the scenario. Although her history warrants attention, she is not the first priority compared to the client with an abnormal fetal heart rate.
Choice D is incorrect. This client is in early labor, and while she has reached 3 cm cervical dilation, this phase allows time for assessment and monitoring before active labor begins. Additionally, there are no known complications mentioned in the scenario, which suggests that she is in a stable condition.
Related Videos
4 Key Topics
ABCs: Airway
15.5 Prioritization Part 1
Spectrum of Stability
15.5 Prioritization Part 1
Additional Info
✓ The nurse should promptly inform the healthcare provider about the abnormal fetal heart rate and continue to communicate any changes or concerns throughout labor. The provider may need to assess the client and make decisions about potential interventions.
✓ Given the abnormal fetal heart rate, the nurse should initiate continuous electronic fetal monitoring to closely assess the baby's heart rate patterns throughout labor. This will help detect any further changes or signs of distress promptly.
✓ This client may benefit from position change(s) as well. Proper positioning can help relieve pressure on the umbilical cord and improve blood flow to the baby.
