The laboring client 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 client on bed rest at this time.
3. Apply an internal fetal scalp electrode.
4. Obtain a clean-catch urine specimen.
2
Explanation: 2. Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse.
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Fill in the blank(s) with correct word
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a. P wave; with the end of the QRS complex b. QRS complex; at approximately the apex of the T wave c. QRS complex; with the end of the T wave d. P wave; with the beginning of the QRS complex