A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:
a. contraction pattern, amount of discomfort, and pregnancy history.
b. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
c. last food intake, when labor began, and cultural practices the couple desires.
d. identification of ruptured membranes, the woman's gravida and para, and her support person.
ANS: B
All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits.
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