A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?
a. Obtain a fetal heart rate.
b. Determine the estimated due date.
c. Auscultate anterior and posterior breath sounds.
d. Ask the client when she last had something to eat.
ANS: C
On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.
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