A nurse is caring for a client who isin active labor and just had an amnioto- my performed by the provider. Which
of the following findings indicates a need for further evaluation?
Select all that apply.
Amniotic fluid is stained with meconium Minimal FHR
variability
A change in the fetal stat...
, 1. A nurse is caring for a client who is in active labor and just had an amnioto- my performed by the provider. Which
of the following findings indicates a need for further evaluation?
Select all that apply.
Amniotic fluid is stained with meconium Minimal FHR
variability
A change in the fetal station from 0 to +2
An abrupt decrease in the FHR below the baseline
Stronger and more frequent uterine contractions: Amniotic fluid is stained with meconium is correct. This is an
unexpected finding that requires further evaluation. Meconium-stained amniotic fluid can indicate fetal distress.
Minimal FHR variability is correct. This is an unexpected finding that requires further evaluation. Minimal or absent
variability can indicate fetal metabolic acidemia or hypoxemia at the time it is observed.
An abrupt decrease in the FHR below the baseline is correct. This is an unexpected finding that requires further evaluation
This finding indicates a variable deceleration, which is a manifestation of cord compression.
2. A nurse in the newborn nursery is caring for a newborn who has jaundice. Which of the following actions
should the nurse take to determine if the jaundice is pathologic?
Determine the newborn's age in hours. Perform a New Ballard
Score assessment. Blanch the skin to assess for a yellow hue.
Request a prescription to obtain a blood specimen for a bilirubin level.: Deter- mine the newborn's age in hours.
The nurse should first confirm the newborn's age in hours to determine if the jaundice is pathologic or physiologic.
Jaundice that appears within the first 24 hr of birth is pathologic and jaundice that occurs after 24 hr is physiologic.
3. A nurse in a prenatal clinic is caring for a client who is at 24 weeks of gestation. Which of the following
findings requires immediate attention? Abdominal bloating and constipation for 2 days
Presence of a third heart sound upon auscultation Shortness of breath and wheezing at
rest
Client report of increased, odorless vaginal discharge: Shortness of breath and wheezing at rest
2/
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