Author Question: The laboring patient has been found to be having moderately strong contractions lasting 60 seconds ... (Read 38 times)

tnt_battle · **on:** Jun 28, 2018

The laboring patient has been found to be 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 patient presents to labor and delivery stating that her water broke two hours ago. Indicators of normal labor include:

1. Fetal heart rate of 130 with average variability.
2. Blood pressure of 130/80.
3. Maternal pulse of 160.
4. Protein of +1 in urine.
5. Odorless, clear fluid on underwear.

annierak · **Reply #1 on:** Jun 28, 2018

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.