The laboring client has experienced spontaneous rupture of ...

[justinmsk]

The laboring client has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100105. Which nursing action is most important?
 
  1. Change the mother's position from Fowler's to left lateral.
  2. Insert a Foley catheter with the assistance of another nurse.
  3. Notify the surgical team of an impending cesarean.
  4. Decrease the IV of lactated Ringer's solution to 50 ml/hour.

Question 2

The client has undergone an ultrasound, which estimated fetal weight at 4,500 g (9 pounds, 14 ounces). Which statement indicates that additional teaching is needed? Because my baby is big:
 
  1. I am at risk for excessive bleeding after delivery.
  2. His blood sugars could be high after he is born.
  3. My perineum could experience trauma during the birth.
  4. His shoulders could get stuck and a collar bone broken.

[ktidd]

Answer to Question 1

1
Rationale:
1. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow.
2. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.
3. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions.
4. Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the client is hypotensive. Decreasing the IV rate will not improve fetal heart tones.

Answer to Question 2

2
Rationale:
1. Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk.
2. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus.
3. Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus.
4. Shoulder dystocia is more common among large fetuses, and a broken clavicle could result.