Nokea
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to notify the provider of the vital signs and the client's condition. The maternal blood pressure of 92/54 mm Hg is low, which can indicate hypotension. Hypotension during labor can lead to decreased perfusion to both the mother and baby, potentially causing harm. Therefore, the provider needs to be notified promptly so that appropriate interventions can be initiated to address the maternal hypotension and ensure the well-being of both the mother and the baby. Positioning the client with one hip elevated, asking about pain medication, and having the client void can be important interventions, but they are not the priority in this situation where maternal hypotension is a concern.