Nokea
The labor and delivery nurse is caring for a 27-year-old primigravida with the following vaginal exam: 2 to 3 cm dilated/70% effaced/-2 station. For the last 2 hours the FHR tracing has displayed a Category I tracing and uterine contractions that are every 2 minutes. The contractions are strong to palpation and the patient is now 3/70%/-2. Which is the nurse’s next best action?
Correct Answer: D
Rationale: The correct answer is D: Document the findings. In this scenario, the patient is in active labor with a Category I FHR tracing, optimal contractions, and progressing cervical dilation. Documenting the findings is important to maintain an accurate record of the patient's progress, which is crucial for monitoring labor and ensuring appropriate care. Encouraging ambulation (choice A) may be unnecessary or even unsafe given the frequency and strength of contractions. Initiating oxytocin (choice B) is not indicated as the patient is already in active labor. Assisting the patient to a warm bath (choice C) may provide comfort but is not the priority at this stage. Therefore, documenting the findings is the next best action to ensure proper documentation and monitoring of the patient's progress.