The charge nurse is looking at the charts of laboring clients. Which client most requires further intervention?
1. Multip at 7 cm, fetal heart tones auscultated every 90 minutes
2. Primip at 10 cm and pushing, external fetal monitor applied
3. Multip with meconium-stained fluid, internal fetal scalp electrode in use
4. Primip in preterm labor, external monitor in place
1
Rationale:
1. During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is too infrequently.
2. External monitoring can be used instead of auscultation of the fetal heart tones during labor.
3. Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present.
4. External monitoring during preterm labor will assess both contractions and fetal status.
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