A nurse is assisting with the care of a client who is in active labor.

Admission Assessment.

1130: Client admitted to labor and delivery.

Gravida 1, para 0 at 40. weeks of gestation.

Client presents with contractions every 5 to. 6 min, 30 to 40 seconds duration, 2+ intensity.

Client reports their water broke and the fluid was clear.

Positive for group B. streptococcus B-hemolytic at 37 weeks.

Sterile vaginal examination by RN. Cervix 5 cm dilated, 50% effaced.

0 station.

The nurse is assisting with the care of the client following the insertion of an epidural.

For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Nursing Intervention

Essential

Contraindicated?

Explanation

Place the client in left lateral position.

Yes

No

This position improves maternal and fetal blood flow and reduces the risk of hypotension.

Decrease the IV flow rate.

No

Yes

This intervention is contraindicated because the client may need fluid boluses to maintain adequate blood pressure and hydration.

Assist with administration of ampicillin I.

Yes

No

This intervention is essential because the client is positive for group B streptococcus and needs antibiotic prophylaxis to prevent neonatal infection.

Monitor fetal heart rate.

Yes

No

This intervention is essential because epidural analgesia can affect uterine contractility and fetal oxygenation.

Request a prescription for ephedrine.

No

No

This intervention is neither essential nor contraindicated. Ephedrine is a vasopressor that can be used to treat hypotension caused by epidural analgesia, but it is not routinely prescribed unless the client develops symptoms of hypotension.