23-year-old G1P0, who came in for an induction this morning at 39 weeks and 5 days. She had an uncomplicated prenatal co

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23-year-old G1P0, who came in for an induction this morning at
39 weeks and 5 days. She had an uncomplicated prenatal course
except she is positive for Group B strep and occasionally uses an
inhaler for her asthma. Her labor has progressed slowly. She’s now
4 cm/90% effaced and +1 station. She ruptured membranes about 30
minutes ago, and it was clear. Contractions every 90 seconds,
lasting 45 seconds.
Pulse 90
BP 135/85
Temp 37.2
FHR 140, Category 1
Her vitals have been within normal limits all day. She’s been at
an oxytocin rate of 20 milliunits/min since about noon. She doesn’t
want an epidural yet. Her husband just left 15 minutes ago to get
some dinner.
1 hr later...
Contractions are now lasting 60 seconds and occurring every 90
seconds.
Pulse 110
BP 140/85
Resp Rate 20
FHR: 130; late decelerations with minimal variability are
occurring with each contraction (Category III). A late deceleration
does not recover to baseline and evolves into a prolonged fetal
bradycardia with FHR of 65.
1. What are 3 priority assessments (physiological
adaptation)?
2. What are 3 risk factors (health promotion and
maintenance/reduction of risk potential)?
3. What are 3 psychosocial concerns?
4. What are 3 priority nursing diagnoses?
5. 3 potential and actual complications from
treatments/procedures?
6. 3 nursing interventions (basic care and comfort/safety and
infection control)?
7. 3 medications?
8. 3 patient teaching?