Immediately following an epidural block, a client's blood pressure falls to 90/50. Which priority action would the nurse take.

Choice A rationale

Green-stained amniotic fluid in a fetus, especially one who is post-term (41 weeks), is highly suggestive of meconium staining. This occurs when the fetus passes its first stool (meconium) in utero. While the meconium is expelled, its presence in the amniotic fluid is often a sign of fetal stress or compromise, which can lead to complications such as meconium aspiration syndrome.

Choice B rationale

Although green or foul-smelling amniotic fluid can indicate intrauterine infection (chorioamnionitis), particularly if accompanied by maternal fever or uterine tenderness, meconium staining is a more common cause in a post-term pregnancy with a breech presentation. Chorioamnionitis involves ascending infection of the membranes and fluid, not solely the color change due to meconium.

Choice C rationale

Neural tube defects, like spina bifida or anencephaly, are congenital structural abnormalities resulting from incomplete closure of the embryonic neural tube. While they can sometimes be associated with oligohydramnios or specific markers, they do not typically cause the amniotic fluid to turn green. Green fluid is a sign of a physiological event, not an anatomical malformation.

Choice D rationale

Meconium passage in utero, resulting in green amniotic fluid, is frequently an indicator of fetal distress or compromise, often due to hypoxia (oxygen deprivation) or umbilical cord compression. The fetus may pass meconium secondary to vagal nerve stimulation from stress. Therefore, the nurse's finding immediately alerts the team that fetal well-being may be acutely threatened, necessitating close monitoring and potential intervention.

Choice A rationale

Abdominal enlargement is considered a probable sign of pregnancy, not presumptive, because conditions other than pregnancy (e.g., tumors, ascites) can cause it. Presumptive signs are those experienced by the woman that are subjective and least indicative of pregnancy, typically beginning earlier than probable signs like abdominal enlargement.

Choice B rationale

Breast changes, such as tenderness, fullness, or darkening of the areolae, are presumptive signs. These changes are subjective and are primarily caused by the elevated levels of estrogen and progesterone, which stimulate the mammary glands and increase vascularity, although other hormonal conditions can also cause them.

Choice C rationale

A positive urine pregnancy test detecting human chorionic gonadotropin (hCG) is classified as a probable sign of pregnancy. While highly suggestive, it is not considered a positive sign because elevated hCG can rarely be caused by conditions like a hydatidiform mole or certain tumors, which are not a viable pregnancy.

Choice D rationale

Goodell sign (softening of the cervix) is a probable sign of pregnancy. It is an objective change noted upon examination, usually around the fifth week, caused by increased vascularity and edema. Probable signs are objective, yet not definite, as they can be caused by other physiological changes.

Choice E rationale

Hearing fetal heart tones with a Doppler (around 10-12 weeks) or a fetoscope (later) is considered a positive sign of pregnancy. Positive signs are those directly attributable only to the presence of a fetus and cannot be confused with any other condition.

Choice F rationale

Urinary frequency is a presumptive sign often seen early in the first trimester. It is caused by hormonal changes and pressure from the enlarging uterus on the bladder. This symptom is subjective and also occurs in non-pregnant states, such as with a urinary tract infection or increased fluid intake.

Choice G rationale

Amenorrhea (absence of menstruation) is a presumptive sign of pregnancy. It is often the first and most classic indicator, but it is subjective and can also be caused by conditions such as stress, hormonal imbalances, or extreme weight changes, making it not definitive on its own.