Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
33. A client, who is a primigravida, is 6 cm dilated, 100% effaced, and a –3 station. She suddenly has a gush of fluid. Which nursing assessments indicate a complication and should be reported to a physician? Select all that apply.
. Green-tinged fluid.
. Copious amount of vernix in clear fluid.
. Decrease in the fetal heart rate baseline from 140 to 100 bpm.
. Increase in the fetal heart rate baseline to 170 bpm.
. Small amount of clear fluid.
Test-Taking Tip
Eliminate the two options about "clear fluid"; a small amount of fluid may be from rupture of membranes, and a copious amount of vernix is normal.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; 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[®]
. . .
Answer 1 is correct because green-tinged fluid is indicative of meconium staining, a possible indicator of fetal distress, and should be reported to the physician. Answer 2 is incorrect because vernix in the fluid is a normal finding after rupture of membranes, and does not need to be reported to the physician. Answer 3 is correct because a decrease in the fetal heart rate baseline to 100 bpm is bradycardia and may indicate umbilical cord prolapse or compression, and should be reported to the physician. Answer 4 is correct because an increase in the baseline fetal heart rate to above 160 bpm can be indicative of an infection, and should be reported to the physician. Answer 5 is incorrect because a small amount of clear fluid is a normal finding after rupture of membranes, and does not need to be reported to the physician.