A nurse is caring for a client in active labor.

Admission Assessment.

0200:. Gravida 1, Para 0 at 39 weeks gestation.

Presents with.

contractions occurring every 5 to 6 min, 45 to 60 seconds.

duration.

Cervical examination 4 cm dilated, 50% effaced.

Admit.

to the labor and delivery unit.

Nurses' Notes.

0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.

of O to 10 with contractions.

Cervix 4 cm dilated, 50% effaced,with membranes intact.

0230:. The client reports increasing discomfort with contractions.

Cervix 5. cm dilated, 60% effaced, with membranes intact.

Contractions.

occurring every 5 min, 45 to 60 seconds duration.

0300:. Epidural anesthesia was initiated.

Cervix 7 cm dilated, 70% effaced,. with membranes intact.

Contractions occur every 4 to 5 min,60 seconds duration.

Vital Signs.

0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.

Respiratory rate 18/min.

BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.

Respiratory rate 20/min.

BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.

Respiratory rate 18/min.

BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.

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

Choice A rationale:

(Correct Choice) Checking the expiration date on the safety inspection sticker of the pump is essential to ensure the equipment is functioning properly and safely. Using expired equipment can compromise the client's safety and the effectiveness of the treatment.

Choice B rationale:

Verifying that the extension cord for the pump is ungrounded is important for electrical safety. However, it is not the nurse's responsibility to do this. This action should be performed by a qualified electrician or facility maintenance personnel.

Choice C rationale:

Reporting the pump with a frayed cord is essential. However, it is not safe to proceed with the infusion in this situation. Using damaged equipment can lead to electrical hazards and compromise the client's safety.

Choice D rationale:

Obtaining a surge protector is important for protecting the pump and other electrical appliances from power surges. While this is a good practice, it is not the first action the nurse should take when preparing to initiate intravenous fluids.

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed