A nurse in an antepartum unit is caring for a client.

Exhibits

Select the 2 findings that require immediate follow-up.

Essential Interventions:

• Monitor fetal heart rate
• Administer ampicillin IV
• Place client in left lateral position
• Request a prescription for ephedrine

Contraindicated Intervention:

• Decrease the IV flow rate

Rationale:

• Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
• Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
• Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
• Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
• Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.