Answer to Question 1
Correct Answer: 2
Rationale 1: It is unknown from the given information whether it is culturally appropriate for the patient's husband to remain in the room for the labor and birth.
Rationale 2: Because the membranes are ruptured and the head is high in the pelvis at a 2 station, the patient should be maintained on bed rest to prevent cord prolapse.
Rationale 3: An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This patient has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present.
Rationale 4: A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid contamination might falsely increase the protein present. Preventing cord prolapse, which is life-threatening to the fetus, is a higher priority.
Answer to Question 2
Correct Answer: 1,2,5
Rationale 1: FHR 120160 with variability is a normal indication.
Rationale 2: Maternal vital sign of blood pressure below 140/70 is a normal indication.
Rationale 3: A pulse of 60100 is a normal indication.
Rationale 4: Proteinuria of +1 or more could be a sign of pre-eclampsia.
Rationale 5: Fluid clear and without odor is a normal indication.
The nurse can make observations about the patient's general appearance while talking with the p
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