Final answer:
The nurse's priorities for a laboring client include assessing fetal heart rate, monitoring maternal blood pressure, evaluating contractions, and notifying healthcare providers about any symptoms like light-headedness. Janine's IV infusion of pitocin is to stimulate uterine contractions to aid labor progression.
Step-by-step explanation:
Priority Nursing Actions for a Pregnant Client
When determining the nurse's priorities for a laboring client like Janine who is 41 weeks pregnant, several actions are crucial:
- Assessing the fetal heart rate for decelerations is essential because these can indicate fetal distress, which might necessitate emergency interventions such as a Caesarian section.
- Monitoring the maternal blood pressure for changes is crucial to detect any signs of hypertension or hypotension, which can impact both the mother and fetus.
- Evaluating the frequency and intensity of uterine contractions helps track the progression of labor, ensuring that the contractions are effective in dilating the cervix.
- Notifying the healthcare provider about the client's light-headedness could indicate possible complications such as hypotension, dehydration, or other issues needing immediate attention.
The IV infusion of pitocin that Janine is receiving is used to stimulate uterine contractions, which are necessary to progress labor given that she has been having protracted labor with minimal cervical dilation.