The labor and delivery nurse is planning care needs for clients in labor. Which client is the priority for further intervention?
1. Multipara at 7 cm, fetal heart tones auscultated every 90 minutes
2. Primipara at 10 cm and pushing, external fetal monitor applied
3. Multipara with meconium-stained fluid, internal fetal scalp electrode in use
4. Primipara in preterm labor, external monitor in place
1. Multipara at 7 cm, fetal heart tones auscultated every 90 minutes
Rationale:
During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is too infrequent. This is the client that should receive further intervention first. External monitoring can be used instead of auscultation of the fetal heart tones during labor for the primipara at 10 cm and pushing. Meconium-stained amniotic fluid is not an expected finding; however, internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. This client is being treated appropriately and would not need intervention first. External monitoring during preterm labor will assess both contractions and fetal status, so the primipara in preterm labor will not be the priority for intervention. .
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