HESI - OB, Artificial Rupture of Membranes
The practitioner has just performed an amniotomy on a patient in active labor. As the practitioner turns to leave the room, the nurse notices that the FHR has increased to 160 bpm for 25 seconds and the baseline is 135 bpm. What is the next appropriate nursing action? A. Continue to monitor the FHR, because accelerations may be a normal response to the procedure. B. Call the practitioner back because of Category II (indeterminate) FHR tracing characteristics. C. Assess the maternal temperature, because the fetus may be showing signs of infection. D. Leave the room with the practitioner to assess other patients
A. Continue to monitor the FHR, because accelerations may be a normal response to the procedure. Rationale: FHR accelerations may result from scalp stimulation during an AROM; this is a normal response to the procedure. The FHR acceleration to 160 bpm and the baseline rate of 135 bpm are characteristic of a Category I (normal) tracing; however, decelerations or bradycardia would not be normal and would warrant asking the practitioner to return to the room for further assessment. Because the procedure has just been performed, the increase in FHR is more likely to be related to the procedure than to an infection, so the nurse does not need to take the patient's temperature. Leaving the room to assist the practitioner with rounds is inappropriate because the nurse should monitor the FHR until it returns to baseline.
The nurse-midwife is preparing to perform an AROM on a patient who has been in labor for 8 hours. After the procedure, what is the intrapartum nurse's most important assessment to rule out cord compression or umbilical cord prolapse? A. FHR characteristics B. Maternal temperature C. Color, clarity, odor, and consistency of amniotic fluid D. Cervical dilation and effacement
A. FHR characteristics Rationale: Changes in the FHR characteristics immediately after an AROM may indicate umbilical cord prolapse or cord compression. Maternal temperature should be assessed at least every 2 hours but not immediately after the procedure because signs of infection are not likely to occur until later. Although assessing the amniotic fluid color, clarity, odor, and consistency is important, these characteristics would not be indicative of umbilical cord prolapse. The practitioner should have assessed cervical dilation and effacement during the procedure; a separate examination immediately after the procedure is not needed because each cervical examination, especially after membrane rupture, increases the chances of maternal-fetal infection.
After AROM is performed on a patient at 37 weeks' gestation who is being induced for preeclampsia, the nurse observes a large amount of vernix in the fluid. What situation may be indicated by this sign? A. Infection B. Fetal prematurity C. Fetal hypoxia D. A normal finding in a term pregnancy
B. Fetal prematurity Rationale: A large amount of vernix in the amniotic fluid may indicate fetal prematurity. Vernix in the amniotic fluid does not indicate infection or fetal hypoxia. Small pieces of vernix may be observed in the amniotic fluid following AROM as a normal finding in a term pregnancy, but a large amount of vernix is not normally found in amniotic fluid in a term pregnancy
The practitioner has just performed an AROM on a multipara at 39 weeks' gestation. Green meconium-stained amniotic fluid with little to no odor is noted. What does this fluid indicate? A. An infection of the amniotic fluid B. Interruption of oxygenation to the fetus C. A normal finding D. The need for newborn resuscitative measures at delivery
B. Interruption of oxygenation to the fetus Rationale: Green or muddy yellow meconium-stained amniotic fluid indicates interruption of oxygenation to the fetus. Meconium-stained amniotic fluid may indicate the need for resuscitative measures for the newborn after delivery, such as positive pressure ventilation, but this is not always the case. Amniotic fluid with a foul odor or purulence can indicate signs of infection (chorioamnionitis), but infection is not always present, and the fluid described here is not foul-smelling or purulent. Green meconium-stained amniotic fluid is not a normal finding.
A multipara with hydramnios is admitted in active labor. After 3 hours of labor, the patient's cervix is 7 cm dilated, and the amniotic membranes are intact. The fetal presenting part is at −3 station. Uterine contractions are occurring every 3 to 5 minutes, and the cervix and fetal station have remained unchanged for 2 hours. The obstetrician asks the APRN to perform an AROM. Based on the patient's assessment data, for which condition is the patient at greatest risk? A. Prolapsed cord, because of the current cervical dilation B. Prolapsed cord, because of the current fetal station C. Infection, because of the duration of labor D. Cesarean delivery, because of multiparity
B. Prolapsed cord, because of the current fetal station Rationale: Serious risks associated with an AROM are compression or prolapse of the umbilical cord, infection, and rupture of undiagnosed vasa previa. This patient is at risk for a prolapsed umbilical cord, because the fetal presenting part is at −3 station, indicating that the presenting part is not applied to the cervix. If the fetal part were firmly applied to the cervix, the patient would not have an increased risk of cord prolapse, regardless of the degree of cervical dilation. The patient's labor is not prolonged, so the risk of infection is not increased because of duration of labor. Cord prolapse, not multiparity, is a risk factor for cesarean delivery associated with AROM.
The nurse is preparing a patient for an AROM. The patient appears anxious, and comments, "I'm worried that the procedure will be painful." Which statement is the best response by the nurse? A. "Artificial rupture of membranes doesn't hurt, but the vaginal examination does." B. "Artificial rupture of membranes is painful, but we'll monitor you closely." C. "The procedure itself will feel similar to the other vaginal examinations you've had today." D. "Don't worry, you'll be fine."
C. "The procedure itself will feel similar to the other vaginal examinations you've had today." Rationale: Acknowledging that the procedure should feel like a sterile vaginal examination, which may be somewhat uncomfortable depending upon the patient, is important. The patient should not feel the AROM, and the sterile vaginal examination might be considered uncomfortable but should not be painful. Misleading the patient regarding discomfort related to the procedure is inappropriate, as is dismissing the patient's concerns
A patient in labor at 41 weeks' gestation underwent an AROM 6 hours ago. The nurse has been assessing the patient's temperature every 2 hours. The nurse should notify the practitioner if the patient's temperature reaches what elevation? A. 37°C (98.6°F) B. 37.4°C (99.3°F) C. 38°C (100.4°F) D. 36°C (96.8°F)
C. 38°C (100.4°F) Rationale: The nurse should notify the practitioner if the patient's temperature reaches 38°C (100.4°F). A temperature of 36°C (96.8°F) is below normal, and 37°C (98.6°F) is normal. The patient with a temperature of 37.4°C (99.3°F) should be monitored for any further elevation.
The practitioner has just performed an AROM on a primigravida at 39 weeks' gestation. A gush of blood is noted with the rupture of membranes. On palpation, the uterus is soft (i.e., relaxed) and the patient is not reporting any pain. An FHR deceleration down to 90 bpm is noted. What does the nurse suspect has happened? A. Placental abruption B. Umbilical cord prolapse C. Ruptured vasa previa D. Bleeding from the cervix
C. Ruptured vasa previa Rationale: A ruptured vasa previa would explain the painless gush of blood with a soft uterine resting tone and fetal heart rate deceleration. The likelihood of a placental abruption in this circumstance is low because the uterus is soft and the patient is not in any pain. With a placental abruption, the uterus has increased tone and the patient experiences increased pain. An umbilical cord prolapse would not cause a gush of blood. Bleeding from the cervix would not explain the FHR deceleration with the gush of blood.
A patient presents to the triage area in labor at 40 weeks' gestation. The patient states, "My waters broke and I've been leaking for the past 24 hours." The patient has not had a GBS culture. The nurse knows that when caring for a patient with an unknown GBS status, antibiotics should be started after the membranes have been ruptured for how long? A. 24 or more hours B. 36 or more hours C. 12 or more hours D. 18 or more hours
D. 18 or more hours Rationale: When GBS culture results are unknown at the onset of labor, antibiotics should be administered to a patient with intrapartum risk factors for GBS early onset disease. These risk factors include a significant risk of preterm birth, PPROM or a rupture of membranes at term that occurred 18 or more hours ago, or fever (a temperature 38°C [100.4°F] or higher). A patient with rupture of membranes lasting 12 hours does not need antibiotics unless other signs or symptoms of infection are noted. Waiting for 24 to 36 hours or more is too long before administering antibiotics to a patient whose membranes have been ruptured for 18 or more hours.
The nurse performs an assessment and a sterile vaginal examination on a patient who presents to the unit with uterine contractions. The patient's cervix is 3 cm dilated and 90% effaced; the fetus is at 0 station. The FHR is 150 bpm, and the patient's contractions are occurring every 3 to 4 minutes; they last 60 seconds and are firm to palpation. Why would performing AROM be appropriate? A. The contraction pattern is adequate. B. The patient's cervix is dilated to 3 cm. C. The FHR is high. D. The fetal presenting part is applied to the cervix.
D. The fetal presenting part is applied to the cervix. Rationale: The fetal head should be well applied to the cervix before an AROM to help prevent umbilical cord prolapse. Knowing the extent of cervical dilation before the AROM is important, but it is not the only consideration when preparing for an AROM. The FHR is normal and is not a contraindication for AROM. The goal of an AROM is to stimulate a uterine contraction pattern to shorten labor. An AROM could cause contractions to occur closer together, facilitating dilation.
