Health Promotion and Maintenance
38. A nurse gives a report on a client who is 29 years old, gravida 2, para 1 at 32 weeks' gestation. The fetus is in a vertex presentation and the water bag is intact. A vaginal examination was done 1 hour previously. At that time, the client's cervix was 3 cm dilated and 80% effaced. The station was –2. Continuous EFM is ordered and IV fluids are infusing into the client's left arm. Which is the most important nursing assessment at this time?
. The frequency and duration of contractions.
. The patency of the IV infusion.
. The baseline fetal heart rate.
. The maternal vital signs.
Test-Taking Tip
Consider the gestational age, and which assessment is the most important to perform at the beginning of the shift for a client who is in preterm labor.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Health Promotion and Maintenance
.
Answer 1 is correct because this client is at 32 weeks' gestation, multipara, and 3 cm dilated. The contractions are the most important assessment in a client who is in preterm labor. If the contractions are close together, tocolytics will be required to decrease the contractions. If there are rare or no contractions, the nurse can focus on other assessments. Answer 2 is incorrect because the client is preterm and her contractions are the most important assessment for this client. If her contractions are regular or close together, tocolytics will be required to decrease the contractions. The patency of the IV infusion is not the most important assessment in a client with preterm labor. Answer 3 is incorrect because the client is preterm and her contractions are the most important assessment. The fetal heart rate is an important assessment for all clients in labor, but the most important assessment for this woman who is preterm with a cervix that is dilated and effaced is the frequency and duration of the contractions. If the client is having regular contractions, tocolytics may be required to stop her uterine contractions. Answer 4 is incorrect because the maternal vital signs are a common part of the assessment for all obstetric clients, but this client is preterm and her contractions are the most important assessment. If the client is having regular contractions, tocolytics may need to be ordered to stop the uterine contractions.