A low-risk client is in the second stage of labor. What actions should the nurse take regarding the auscultation of this client's fetal heart rate? Select all that apply
1. Evaluate after ambulation.
2. Assess heart sounds every 15 minutes.
3. Evaluate before the membrane rupture.
4. Evaluate before providing medications.
5. Count for 30 seconds and multiply times 2.
2, 4, 5
Explanation:
1. Fetal heart rate should be assessed before ambulation.
2. For a low-risk client in the second stage of labor heart sounds should be assessed every 15 minutes.
3. Since membrane rupture cannot be predicted, fetal heart rate would be assessed after the rupture of these membranes.
4. Fetal heart rate should be assessed before providing medication.
5. The fetal heart rate should be assessed for 30 seconds and then multiply times 2.
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