Answer :
1.The assessment findings that require immediate nursing action are Uterus feels boggy and The patient reports break through pain level of 7.4(C and D).
2.The intervention that will have priority in this situation is Notifying child protective services(C)
3.The nurse interprets these findings as respiratory distress(D)
4.The most appropriate action in this situation would be continue to monitor contractions and fetal heart rate(B).
1.The assessment findings that require immediate nursing action are:
C. Uterus feels boggy - This indicates uterine atony, which could lead to excessive bleeding and should be addressed promptly.
D. The patient reports breakthrough pain level of 7.4 - Breakthrough pain could indicate inadequate pain management and needs to be addressed to ensure the patient's comfort.
2.The intervention that will have priority in this situation is:
C. Notifying child protective services - The presence of bruising on the pregnant client's abdomen and the reported cause raise concerns about potential abuse. Ensuring the safety of both the client and her unborn child is a top priority.
3.The nurse interprets these findings as:
d. respiratory distress - The newborn's signs and symptoms, including nasal flaring, sternal retractions, increased heart rate, low oxygen saturation, and rapid respiratory rate, indicate respiratory distress. This could be due to a variety of underlying causes and needs prompt attention.
4.The most appropriate action in this situation would be:
b. continue to monitor contractions and fetal heart rate - The current assessment findings (contractions every 6-7 minutes lasting 60 seconds, uterine resting tone at 20mmHg) suggest that labor induction is progressing appropriately. Monitoring the contractions and fetal heart rate allows for ongoing assessment of the patient's condition before making any changes to the oxytocin infusion rate.
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