The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring patient who will have a forceps delivery. Which action or assessment finding requires intervention?
1. Regional anesthesia is administered via pudendal block.
2. The patient is instructed to push between contractions.
3. Fetal heart tones are consistently between 110 and 115.
4. The patient's bladder is emptied using a straight catheter.
2
Rationale 1: Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.
Rationale 2: The patient should push only during contractions, not between contractions.
Rationale 3: These are normal fetal heart tones. No intervention is needed.
Rationale 4: The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head.
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