A client, G2P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to make at this time?

Correct Answer: B

Rationale: Epidural administration can cause hypotension due to vasodilation, so it is crucial to prevent supine hypotension syndrome. Placing a wedge under the woman's side will help prevent aortocaval compression, which can lead to decreased blood return to the heart. This intervention promotes optimal fetal oxygenation and maternal perfusion. Assessing the woman's temperature (choice A) is not the priority in this scenario. While monitoring temperature is important, it is not as critical as preventing potential complications from the epidural. Placing a blanket roll under the woman's feet (choice C) is not the priority at this time. While this can provide comfort and prevent pressure ulcers, it does not address the immediate risk of aortocaval compression. Assessing the woman's pedal pulses (choice D) is not the priority after epidural administration. While neurovascular assessments are important, maintaining proper positioning to prevent hypotension takes precedence in this situation.

Correct Answer: D

Rationale: Massaging the perineum with mineral oil prior to delivery is the correct intervention to decrease the possibility of a perineal laceration. This intervention helps to soften and lubricate the perineal tissues, making them more flexible and reducing the risk of tearing during delivery. Option A, assisting the woman into a squatting position, may actually increase the risk of perineal laceration. Squatting can increase pressure on the perineum, making it more likely to tear during delivery. Option B, advising the woman to push only when she feels the urge, is important for preventing unnecessary tearing but does not directly address the physical preparation of the perineum. Option C, encouraging the woman to push slowly and steadily, is also important for preventing perineal lacerations but does not address the physical preparation of the perineum like massaging with mineral oil does. In conclusion, massaging the perineum with mineral oil is the most effective intervention for decreasing the possibility of a perineal laceration during delivery as it directly prepares and lubricates the perineal tissues for stretching and reduces the risk of tearing.

Correct Answer: D

Rationale: Choice A is incorrect because it is not true that laboring clients are never allowed to eat. In fact, guidelines vary depending on the hospital policy and the progress of labor. Some hospitals may allow light snacks or clear fluids during early labor to keep the client hydrated and maintain energy levels. Choice B is also incorrect because it is not appropriate for the nurse to make assumptions about the client's experience during labor. While some women may experience nausea and vomiting during labor, others may feel hungry and want to eat. It is important for the nurse to provide individualized care and support the client's preferences. Choice C is incorrect because it provides a specific time frame for when the dinner tray will arrive, which may not be accurate. Labor is unpredictable, and the nurse should focus on meeting the client's immediate needs rather than making assumptions about when food will be served. Choice D is the correct answer because it acknowledges the client's request for food while also providing appropriate guidance. A heavy meal is discouraged during labor as it can lead to discomfort or complications, but clear fluids are usually allowed. By offering clear fluids whenever the client would like them, the nurse is addressing the client's request in a safe and appropriate manner. This response demonstrates a balance between meeting the client's needs and promoting safety during labor.

Correct Answer: A

Rationale: The nurse should assess the fetal heart before reporting the client's status to the health care provider for several reasons. Firstly, assessing the fetal heart rate provides crucial information about the well-being of the baby. Changes in the fetal heart rate can indicate fetal distress or other complications, which may require immediate intervention. This information is essential for the health care provider to make informed decisions about the next steps in the client's care. On the other hand, assessing the contraction pattern (choice B) is important for monitoring labor progress and identifying any abnormalities in contractions. However, this information is more relevant for assessing the progression of labor rather than the immediate well-being of the baby. The woman's vital signs (choice C) are important for assessing her overall health and well-being, but they do not directly provide information about the baby's status. A contraction stress test (choice D) is a specific test used to evaluate the baby's response to contractions and is not typically performed as part of routine assessment before reporting the client's status to the health care provider. In summary, assessing the fetal heart rate is essential before reporting the client's status to the health care provider because it directly reflects the baby's well-being and can guide immediate management decisions. The other choices, while important for monitoring labor progress and assessing the client's health, do not provide as direct or immediate information about the baby's status.

Correct Answer: A

Rationale: Based on Leopold's maneuvers, the first step involves palpating the fundus of the uterus to determine the fetal part present in the fundal region. In this scenario, the buttocks are felt in the fundal region, indicating a breech presentation. This rules out choices A and C, as they both involve the head being in the fundal region. The next step is to palpate the sides of the mother's abdomen to determine the back and small parts of the fetus. In this case, the back is felt on the mother's left side, while the small parts are felt on her right. This positioning corresponds to the baby's back being on the left side of the mother's abdomen and the limbs on the right side, which is indicative of a left occiput anterior (LOA) position. Choice B (Left sacral posterior) is incorrect because the back is felt on the left side, not the sacrum. Choice C (Right mentum anterior) is incorrect because the back is felt on the left side, not the right. Choice D (Right sacral posterior) is incorrect because the back is felt on the left side, not the sacrum, and the head is not in a posterior position. Therefore, the correct answer is A (Left occiput anterior) based on Leopold's maneuvers, which involve palpating the fundus, determining the back and small parts, and identifying the position of the fetal head.