When the membranes of a pregnant patient rupture during labor, ...

[sc00by25]

When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture?
 
  A) Meconium-stained amniotic fluid
  B) Fetus presenting in an LOA position
  C) Maternal pulse of 90 to 95 beats/min
  D) Blood-tinged vaginal discharge at full dilation

Question 2

The fetus of a patient in labor is in a vertex presentation and at a 1 station. How should the nurse interpret the location of the fetal head?
 
  A) Floating
  B) Engaged
  C) Crowning
  D) At the ischial spines

[lucas dlamini]

Answer to Question 1

A
Feedback:
Meconium staining means that the fetus has lost rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. The fetal presentation is not assessed during membrane rupture. The maternal pulse rate of 90 to 95 beats/min is expected during labor. Blood-tinged vaginal discharge at full dilation is an expected finding.

Answer to Question 2

A
Feedback:
Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. The degree of engagement is established by vaginal and cervical examination. Station refers to the relationship of the presenting part of the fetus to the level of the ischial spines. If the presenting part is above the spines, the distance is measured and described as minus stations, such as 1 . The fetal head is currently floating. The head would be engaged if it were at the level of the ischial spines. Crowning is when the top of the fetal head is visible and birth is imminent.