A woman with a history of heart failure is in labor and has the following vital signs: blood pressure: 100/58 mm Hg, pulse: 120 beats/minute, respiratory rate: 36 breaths/minute, oxygen saturation: 88%. Which action should the nurse perform first?
A.
Administer oxygen at 10 L/min per rebreather mask.
B.
Call the health-care provider to report the results.
C.
Document the findings in the patient's chart.
D.
Increase the woman's IV infusion to 150 mL/hour.
ANS: A
The patient is exhibiting signs of decreased cardiac output and her low SaO2 indicates that she needs oxygen, which should be supplied at 10 L/min per rebreather mask. Calling the provider and documentation are important actions but do not take priority over promptly treating the woman. She does not need increased IV fluids, and, in fact, increasing the IV fluid rate will likely worsen her condition.
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