A patient in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the patient. Which priority intervention should be performed in order to evaluate the clinical response to treatment?

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Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring patient but used for postoperative and/or chronic pain patients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this patient's situation. Increasing the flow rate of parenteral fluids requires a physician's order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.

A Patient in Labor Is Approaching the Transition Stage and Already