Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
29. Suddenly, during a labor contraction, a pregnant client experiences a gush of amniotic fluid. Which assessment finding should indicate to a nurse that the client is experiencing a deviation from normal labor patterns?
. Colored amniotic fluid.
. Fetal bradycardia with contractions.
. The client complains of nausea and vomits.
. The client becomes diaphoretic and irritable.
Test-Taking Tip
Carefully read the stem of the question; it is asking for the answer that is not a normal part of labor. Eliminate the answers that are a normal physiological part of labor.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because normal amniotic fluid is basically colorless; any color may signify fetal or maternal problems. For example, yellow or green amniotic fluid indicates meconium release due to fetal hypoxia or breech presentation; bloody amniotic fluid may indicate a placental abruption or marginal placenta previa. Answer 2 is incorrect because fetal bradycardia commonly occurs at the acme of the contraction, due to head compression, which is a benign condition. Answer 3 is incorrect because nausea with or without emesis is common in labor, due to physiological stress. Answer 4 is incorrect because diaphoresis and irritability are signs of transitional phase of labor.