A client states that her water broke 2 hours ago. What findings should the nurse identify as indications of normal labor? Select all that apply
1. Protein of +1 in urine
2. Maternal pulse of 160
3. Blood pressure of 120/80
4. Odorless, clear fluid on underwear
5. Fetal heart rate (FHR) of 130 with average variability
3, 4, 5
Explanation:
1. Proteinuria of +1 or more could be a sign of preeclampsia.
2. A pulse of 60 to 100 is a normal indication.
3. Maternal vital sign of blood pressure below 120/80 is a normal indication.
4. Fluid clear and without odor is a normal indication.
5. FHR 120 to 160 with variability is a normal indication.
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