EDAPT INTRAPARTUM PERIOD NURSING CARE
The birthing process represents a major life event for clients and their families, regardless of the number of
previous deliveries. The nurse is responsible for caring for the pregnant woman, family, and fetus throughout
labor and delivery.
When admitting a client to the labor and delivery unit, which is the priority assessment?
The assessment and evaluation of contractions are necessary to establish baseline data. Without adequate
frequency and duration of contractions, labor may fail to progress.
Though it is important to understand the client's pregnancy history, as this may impact the speed and
progression of labor, it is not the priority assessment. While having a labor partner is helpful as labor
progresses, it is not the priority assessment during admission. Documenting the time of last meal is important,
especially if cesarean birth is necessary. However, this is not the priority assessment during admission.
The nurse is caring for a client in labor who is receiving oxytocin. Which assessment finding requires
immediate action?
Uterine tachysystole (hyperstimulation) is defined as more than 5 contractions in 10 minutes (or contractions
closer than 2 minutes in frequency). Tachysystole can result in decreased fetal oxygenation and requires
immediate action.
Urine output of at least 30 mL/hour is not concerning. Fetal heart rate between 110-160 bpm with moderate
variability is normal. Contraction duration of 50-60 seconds is an indication for oxytocin use.
What are indications for labor induction? Select all that apply.
Indications for labor induction may include:
 Maternal factors:
 premature or prolonged rupture of membranes
 preeclampsia/eclampsia
 history of fetal stillbirth or demise
 diabetes mellitus
 history of precipitous (less than 3 hours) labor
 chorioamnionitis
 oligohydramnios
 post-term gestation
 Fetal factors:
 intrauterine growth restriction (IUGR)
 non-reassuring fetal heart rate and pattern
 fetal complications, such as erythroblastosis fetalis and hydrops
 significant congenital anomalies
Maternal request for convenience is not an indication for induction of labor. Labor induction is contraindicated
with placenta previa. A cesarean birth is necessary.