A nurse is caring for a G1 P0 client who is fully dilated, 100% effaced, the fetal head is at +2 station, and had a spontaneous rupture of membranes with clear fluid. The nurse has been coaching the client through pushing with contractions for approximately 3 hours, without significant fetal descent. The nurse notes that although the fetal heart rate is normal, the client is experiencing a prolonged second stage of labor and is now too exhausted to push effectively. The nurse communicates this assessment with the Obstetrician on call. A few minutes later the Obstetrician enters the room and begins preparing the delivery tray. The Obstetrician adds Simpson's forceps to the delivery tray and begins inserting the right forcep inside into the vaginal orifice.
What is the nurse's priority concern ?

Ramanpreet Kaur Sidhu

ID: 137304

Question

A nurse is caring for a G1 P0 client who is fully dilated, 100% effaced, the fetal head is at +2 station, and had a spontaneous rupture of membranes with clear fluid. The nurse has been coaching the client through pushing with contractions for approximately 3 hours, without significant fetal descent. The nurse notes that although the fetal heart rate is normal, the client is experiencing a prolonged second stage of labor and is now too exhausted to push effectively. The nurse communicates this assessment with the Obstetrician on call. A few minutes later the Obstetrician enters the room and begins preparing the delivery tray. The Obstetrician adds Simpson's forceps to the delivery tray and begins inserting the right forcep inside into the vaginal orifice.  
    What is the nurse's  priority concern ? 
 
   Ramanpreet Kaur Sidhu   
 
 ID: 137304

Accepted Answer

Informed consent has not been obtained

Answer

The client's spouse is squeamish and may faint at the sight of the forceps

Answer

This clinical situation does not warrant the use of forceps

Answer

The Obstetrician has not discussed the plan of care

Crowdly

A nurse is caring for a G1 P0 client who is fully dilated, 100% effaced, the fet...

Want instant access to all verified answers on qbank.nurseachieve.com?