The nurse is caring for a client at 39 weeks gestation in active labor. The client had a spontaneous rupture of membranes 2 hours ago with clear amniotic fluid noted. The client was 7 cm at the time of SROM. The nurse assesses the fetal heart rate monitor and identifies a fetal heart baseline of 145 bpm, with moderate variability, accelerations absent and recurrent variable decelerations.
Which of the following interventions should the nurse take? Select all that apply.
Notify the provider.
Encourage the client to ambulate in the hallway.
Reposition the patient to the left lateral position.
Perform a sterile vaginal exam.
Correct Answer : A,C,D,E
Choice A rationale
Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to
monitor labor progression.
Choice B rationale
Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.
Choice C rationale
Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.
Choice D rationale
Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.
Choice E rationale
Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord
compression effects. .
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Correct Answer is C
Explanation
Choice A rationale
A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms
of preeclampsia appear.
Choice B rationale
A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.
Choice C rationale
A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.
Choice D rationale
A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.
Correct Answer is A
Explanation
Choice A rationale
Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) occurs when amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream, triggering
a serious reaction. It can cause sudden shortness of breath, cardiovascular collapse, and other severe symptoms immediately after a rupture of membranes and is a rare but critical
obstetrical emergency.
Choice B rationale
Abruptio placentae involves the premature separation of the placenta from the uterine wall, which leads to bleeding and potential fetal and maternal distress. However, it does not
typically present with sudden cardiorespiratory collapse or shortness of breath immediately following membrane rupture.
Choice C rationale
Uterine rupture refers to a tear in the wall of the uterus, usually due to trauma, labor stress, or previous surgical scars. While it is a severe condition, it usually presents with
abdominal pain, vaginal bleeding, and fetal distress rather than sudden respiratory failure.
Choice D rationale
Disseminated intravascular coagulation (DIC) is a condition affecting blood clotting processes, often secondary to other conditions like severe preeclampsia, sepsis, or trauma. It
generally presents with bleeding and clotting issues but not sudden respiratory or cardiovascular collapse.