The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention?
1. Bladder is emptied using a straight catheter.
2. The client is instructed to push between contractions.
3. Fetal heart tones are consistently between 110 and 115.
4. Regional anesthesia is administered via pudendal block.
2
Explanation:
1. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head.
2. The client should only push during contractions, not between contractions.
3. These are normal fetal heart tones. No intervention is needed.
4. Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.
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