A client who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action?
a. Notify the health care provider promptly.
b. Observe for abnormally high uterine resting tone.
c. Decrease the rate of nonadditive intravenous fluid.
d. Reposition the client with her hips slightly elevated.
ANS: A
Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the client at high risk for uterine rupture. The client is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the client with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.
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