The nurse has collected the following data on a client in labor: the fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds
Using this information, the nurse should take which most appro-priate action? 1. Prepare for imminent delivery.
2. Continue to monitor the client.
3. Report the findings to the obstetrician.
4. Report the FHR to the anesthesiologist on call.
2
Rationale: The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring. The FHR is normally 120 to 160 beats/min. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR.
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