A nurse is caring for a female client, age 32, at 28 weeks of gestation, admitted to the antepartum unit with a diagnosis of HELLP syndrome.

The nurse is assessing the client 15 minutes later. For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client’s condition is improving, or an indication that the client’s condition is worsening.

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.

Choice A rationale

The specific volume of formula for gavage feeding a newborn, such as 20 mL, depends on the newborn's weight, gestational age, and clinical condition. A blanket recommendation of 20 mL without this individualized assessment is inappropriate and could lead to over or underfeeding, impacting growth and gastrointestinal tolerance.

Choice B rationale

Placing a newborn in a supine position immediately after gavage feedings increases the risk of aspiration, especially for infants with immature swallowing reflexes or reflux. The newborn should be positioned on their right side or semi-Fowler's position to facilitate gastric emptying and minimize aspiration risk.

Choice C rationale

While cluster feeding (multiple feedings close together) is a natural pattern for some breastfed infants, for gavage feeding, regular, scheduled intervals are typically maintained to ensure consistent nutrient delivery and proper digestion, especially in newborns who are medically fragile. Cluster feeding is not a standard gavage feeding practice.

Choice D rationale

Nonnutritive sucking (e.g., pacifier use) during gavage feedings is crucial for promoting oral motor development and associating the feeling of fullness with sucking. This helps prevent oral aversion and prepares the newborn for eventual oral feeding, stimulating gastric secretions and improving digestion.