EHR Continued Nursing 2/11 1200 Neuro/Cognitive: A/Ox3. S…
EHR Continued Nursing 2/11 1200 Neuro/Cognitive: A/Ox3. Speech even and clear. Pupils 3 mm PERRLA. Denies any visual changes or disturbances. DTRs 4+, +clonus-one beat. Epidural in place. Client able to move legs slightly. No sensation up to hips. Respiratory: Lung sounds clear bilaterally, breathing unlabored. Cardiovascular: Apical pulse 76 beats per minute, regular, S1 & S2 sounds present. Peripheral Vascular: Skin pink, warm, and dry. +3 pitting edema in left and right lower extremities. Gastrointestinal: Abdomen distended consistent with pregnancy. Bowel sounds present. Last bowel movement two days ago. Genitourinary: Indwelling urinary catheter in place, draining freely. Urine dark yellow, clear. Pain: Client denies feeling any pain, only pressure from contractions. 2/11 1200 Nursing Note: Contractions palpated, moderate intensity, occurring every 2-2 ½ minutes lasting 80-100 sec. Fetal heart rate tracings indicate late decelerations. Sterile vaginal exam performed. Client is 7 cm dilated, 80% effaced, at 0 station. Client’s sister at the bedside for support. intake and output Date Intake Source & Amount Output Source & Amount 2/11 1100 IV Fluids: 125 mLIce chips: 240 mL Urine: 40mL 2/11 1200 IV Fluids: 125 mLIce chips: 240 mL Urine: 35 mL Before answering this question, review the client’s health information in the EHR. The nurse will implement the following interventions based on the fetal heart rate tracings. Select all that apply.