A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -1. Which of the following interpretations of this finding should the nurse make?

Choice A Reason:

Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are

A. Applying sacral counterpressure can help alleviate back pain during contractions.

Choice B Reason:

Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.

Choice C Reason:

Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.

Choice D Reason:

Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.