If the nurse suspects a complication of a low forceps birth labor, she should immediately:
a. administer a strong oral analgesic.
b. assess the perineal and vaginal areas.
c. assess the position of the uterine fundus.
d. review the labor record for duration of second stage.
ANS: B
A low forceps birth may result in significant vaginal trauma. Assessment will provide information on the extent of trauma of the perineum and vagina. Administering an analgesic may interfere with obtaining an accurate assessment of the problem, assessing the position of the uterine fundus will not provide any information on vaginal or perineal trauma, and reviewing the labor record may support the suspicion that trauma has occurred but will not identify extent of trauma.
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