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