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