The nurse is caring for a high-risk client in the second stage of labor. After which actions should the nurse assess the fetal heart rate? Select all that apply
1. Vaginal examination
2. Urinary catheterization
3. Ingestion of clear liquids
4. Administration of pain medication
5. Change in oxytocin administration
1, 2, 4, 5
Explanation:
1. For the high-risk client in the second stage of labor fetal heart rate should be assessed after a vaginal examination.
2. For the high-risk client in the second stage of labor fetal heart rate should be assessed after urinary catheterization.
3. The client in labor will be kept at nothing by mouth status.
4. For the high-risk client in the second stage of labor fetal heart rate should be assessed after administration of pain medication.
5. For the high-risk client in the second stage of labor fetal heart rate should be assessed after a change in oxytocin administration.
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