Which client requires immediate intervention by the labor and delivery nurse?
1. Primipara in active labor with urine output of 100 mL/hour
2. Primipara that delivered 1 hour ago with white blood cells (WBCs) of 50,000
3. Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg
4. Multipara at 5 cm with a respiratory rate of 22 between contractions
2
Explanation:
1. This is a normal urine output and requires no further intervention.
2. A white count of 25,000 to 30,000 is normal at the end of labor and during the early postpartum period. This WBC count is abnormally high and requires further assessment and provider notification.
3. The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor.
4. The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This client requires no further intervention.
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