Which intervention would be most effective if the fetal heart ...

[gbarreiro]

Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes?
 
  a. Apply oxygen at 8 to 10 L/min.
  b. Stop the Pitocin infusion.
  c. Position the client in the knee-chest position.
  d. Increase the main line infusion to 150 mL/hr.

Question 2

Which finding by the nurse on a vaginal exam would be a concern if a spontaneous rupture of the membranes occurred?
 
  a. Cephalic presentation
  b. Left occiput position
  c. Dilation 2 cm
  d. Presenting part at -3 station

[CourtneyCNorton]

Answer to Question 1

ANS: C
A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.

Answer to Question 2

ANS: D
If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.