The laboring client has been found to be having moderately strong contractions lasting 60 seconds every three 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 client on bedrest at this time.
3. Apply an internal fetal scalp electrode.
4. Obtain a clean-catch urine specimen.
2
Rationale:
1. It is unknown from the given information whether it is culturally appropriate for the client's husband to remain in the room for the labor and birth.
2. Because the membranes are ruptured, and the head is high in the pelvis at a −2 station, the client should be maintained on bedrest to prevent cord prolapse.
3. An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This client has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present.
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.
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