Author Question: The laboring patient is having moderately strong contractions lasting 60 seconds every 3 minutes. ... (Read 86 times)

Deast7027 · **on:** Jun 27, 2018

The laboring patient is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100 effaced.

The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Encourage the husband to remain in the room.
2. Keep the patient on bed rest at this time.
3. Apply an internal fetal scalp electrode.
4. Obtain a clean-catch urine specimen.

Question 2

The nurse educator is teaching a group of teens and 20-year-olds reproductive health care. When several of the women bring up douching, the best remark the nurse could make is:

1. One should always douche after having intercourse..
2. When douching, use the prepared products, as one can use force putting them in and get the solution up high..
3. It is a good idea to douche before intercourse so the area is clean for the sperm..
4. Douching is unnecessary because the lining of the vagina has numerous glands that provide natural cleansing..

Bison · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

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 reading of protein present.

Answer to Question 2

4
Rationale 1: Douching after intercourse is not advisable, as it can force bacteria into the uterus.
Rationale 2: Douching is not advisable, as it can force bacteria and foreign substances onto the uterus.
Rationale 3: There is no reason to douche before intercourse. The sperm need the natural pH of the vagina in order to travel where they need to go.
Rationale 4: This is a true statement. The vagina has a natural cleansing system.