The nurse is training a nurse new to the Labor and Delivery unit. They are caring for laboring client who is undergoing a forceps delivery. Which action requires intervention?
1. Regional anesthesia is administered via pudendal block.
2. The client is instructed to push between contractions.
3. Fetal heart tones are consistently between 110 and 115.
4. 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.
2. The client should only push during contractions, not between contractions.
3. These are normal fetal heart tones. No intervention is needed.
4. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head.
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