A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client
Which priority intervention should be done by the nurse to help evaluate clinical response to treatment?
a. Obtain a pain scale response from the client based on a 0 to 10 scale.
b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations.
c. Document intake and output on the electronic health record (EHR).
d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.
ANS: B
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this client's situation. Increasing the flow rate of parenteral fluids requires a physician's order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.
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