A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM, the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings may be an early indication that the client is developing a complication of labor?
1. FHT 168 beats/min
2. Temperature 100 degrees Fahrenheit
3. Cervical dilation of 4 cm
4. BP 138/88
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1 comment:
The correct answer is number: 1
An increase in FHT may indicate maternal infection. The other assessment findings are normal.
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