The graduate nurse (GN) is caring for a laboring client with epidural anesthesia. After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion. Which action by the GN requires the nurse preceptor to intervene?

Question

The graduate nurse (GN) is caring for a laboring client with epidural anesthesia.  After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion.  Which action by the GN requires the nurse preceptor to intervene?

Quizplus · Accepted Answer

11ecbb05_cc0c_95dd_b433_092e336633dc_MD0009_00 An operative vaginal birth uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor. Indications may be maternal (eg, exhaustion, cardiac or cerebrovascular disease) or fetal (eg, abnormal fetal heart rate, arrest of rotation). In a forceps-assisted birth, the health care provider (HCP) gently applies the blades to the sides of the fetal head and locks the handles in place. The HCP applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head. The nurse should never apply fundal pressure during an operative vaginal birth because it may cause uterine rupture (Option A). (Option B) To avoid bladder damage, the nurse should ensure that the client has an empty bladder (eg, catheterization) before the forceps are applied. (Option C) Documentation should reflect birth events accurately for legal purposes and be done in a timely fashion. Birth events can happen quickly, but noting the time when forceps or a vacuum extractor is applied is essential. (Option D) The nurse notifies the HCP when contractions are palpated so that downward/outward traction can be applied to the forceps or a vacuum extractor during the contraction, which helps facilitate the birth. Educational objective: In an operative vaginal birth, forceps or a vacuum extractor is used to shorten the second (pushing) stage of labor. The nurse ensures that the client's bladder is empty, monitors for contractions, and documents the time that forceps or a vacuum extractor was applied. Fundal pressure should never be applied during this procedure or labor/birth.

The Graduate Nurse (GN) Is Caring for a Laboring Client