A nurse is caring for a client who is in a trial of labor for vaginal birth after cesarean (VBAC). The client reports a sudden tearing pain in their back and side that does not feel like a uterine contraction.
Which of the following findings indicates the client may be experiencing a uterine rupture?
Observation of a sudden gush of amniotic fluid.
Hypotension with a blood pressure of 85/40 mm Hg.
Severe bradypnea with a respiratory rate of 10/min.
Palpation of the fetal presenting part in the cervical os.
The Correct Answer is B
Choice A rationale
A sudden gush of amniotic fluid typically indicates rupture of membranes (ROM), which can be spontaneous or induced. While ROM can occur during labor, it is not a direct indicator of uterine rupture, which is a catastrophic event involving the tearing of the uterine wall and often presents with different clinical signs.
Choice B rationale
Hypotension with a blood pressure of 85/40 mm Hg is a critical finding suggesting hypovolemic shock, often due to internal hemorrhage, which is a common consequence of uterine rupture. The sudden loss of maternal blood into the abdominal cavity leads to a rapid decrease in circulating blood volume and subsequent systemic hypotension.
Choice C rationale
Severe bradypnea with a respiratory rate of 10/min is not a primary indicator of uterine rupture. Bradypnea often suggests central nervous system depression, possibly from medication effects or other neurological events, but is not a direct physiological response to the acute blood loss and pain associated with a uterine tear.
Choice D rationale
Palpation of the fetal presenting part in the cervical os is a normal finding during labor progression as the fetus descends. However, if the presenting part is palpated higher or outside the uterus, it can indicate expulsion of the fetus into the abdominal cavity following a complete uterine rupture, which is an abnormal and emergent finding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Late decelerations indicate uteroplacental insufficiency, meaning reduced blood flow and oxygen to the fetus. Placing the client in a lateral position (left or right side) can alleviate pressure on the vena cava, improving venous return to the heart, thus increasing cardiac output and uteroplacental perfusion. This is the least invasive initial intervention.
Choice B rationale
While intravenous fluid administration may be indicated in some cases to improve maternal hydration and placental perfusion, repositioning the client is a more immediate and less invasive intervention to address uteroplacental insufficiency by optimizing maternal circulation and oxygen delivery to the fetus.
Choice C rationale
Preparing for a cesarean birth is a significant intervention reserved for persistent or severe fetal distress that does not respond to less invasive measures. Although late decelerations are concerning, immediate surgical intervention is not the first step without attempting to optimize fetal well-being through maternal repositioning.
Choice D rationale
Elevating the client's legs might slightly increase venous return, but it is not the primary intervention for late decelerations. The lateral position is more effective in relieving aortocaval compression, directly addressing the underlying issue of reduced placental blood flow, and is the established first-line intervention.
Correct Answer is D
Explanation
Choice A rationale
Polyuria, an abnormally large production of urine, is not a typical adverse effect of epidural analgesia. Epidural analgesia, due to its influence on sympathetic nervous system blockade, can sometimes lead to urinary retention by inhibiting bladder detrusor muscle contraction and relaxing the urethral sphincter. Therefore, polyuria would be an unexpected finding.
Choice B rationale
A maternal temperature of 37.4° C (99.4° F) is within the normal physiological range for a laboring client. Slight elevations can occur due to the metabolic demands of labor or dehydration, but this temperature does not indicate an adverse effect directly attributable to epidural analgesia. Fever, defined as a temperature above 38° C (100.4° F), can be associated with epidural use due to thermoregulatory changes.
Choice C rationale
A fetal heart rate of 152/min is within the normal range for a term fetus, typically 110-160 beats per minute. This finding indicates a healthy fetal response and does not suggest an adverse effect of epidural analgesia. Epidural analgesia itself usually does not directly alter the fetal heart rate in a negative way if maternal hemodynamics remain stable.
Choice D rationale
Hypotension is a common adverse effect of epidural analgesia. It occurs due to sympathetic blockade, which causes vasodilation and peripheral pooling of blood, leading to decreased venous return to the heart and a subsequent drop in cardiac output and blood pressure. This reduction in blood pressure can compromise uteroplacental perfusion.
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