Multiple Choice
The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 99° F [37.2° C]. What is the priority nursing action for this patient?
A) Fetal acoustic stimulation
B) Assess temperature every 2 hours
C) Change absorption pads under her hips every 2 hours
D) Review white blood cell count (WBC) drawn at admission
Correct Answer:
Verified
Correct Answer:
Verified
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