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

Exhibits

Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.

Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

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. Wire cutters. This is incorrect because wire cutters are used for clients with wired jaws in case of an emergency but are not needed for chest tube management.
B. Padded clamp. This is correct because a padded clamp is necessary in case the chest tube needs to be momentarily clamped for troubleshooting air leaks or before removal.
C. Montgomery straps. This is incorrect because Montgomery straps are used to secure frequent dressing changes, such as for abdominal wounds, and are not relevant to chest tube management.
D. Tracheostomy tray. This is incorrect because a tracheostomy tray is used for clients at risk for airway obstruction, which is not a routine need following a thoracotomy with chest tube placement.