A primigravida patient has just arrived in the birthing unit

Question

What steps would be most important for the nurse to perform to gain an understanding of the physical status of the patient and her fetus? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode.
2. Auscultate the fetal heart rate between and during contractions.
3. Palpate contractions and resting uterine tone.
4. Assess the blood pressure, temperature, respiratory rate, and pulse rate.
5. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers.

Answer 1

2,3
Rationale 1: A fetal scalp electrode can be applied only if membranes have ruptured and the cervix is at least 3 cm dilated, and is indicated for high-risk pregnancies.
Rationale 2: Fetal heart rate auscultation gives information about the physical status of the fetus.
Rationale 3: Contraction palpation provides information about the frequency, duration, and intensity of the contractions.
Rationale 4: Vital signs do not provide information on the well-being of the fetus.
Rationale 5: Neither Leopold's maneuvers nor a vaginal exam provides information on the well-being of the fetus.