The nurse explains to a pregnant client how ultrasound (US) can aid in the assessment of the fetus.
What would the nurse include in the teaching? Select all that apply.

Choice A rationale

While Group B Streptococcus (GBS) screening is important, the rectovaginal swab is typically performed earlier in pregnancy (35-37 weeks). Given that the client's membranes have ruptured (ROM) and she is in active labor (7 cm dilated), the immediate priority shifts to assessing fetal well-being and preventing complications, making a GBS swab a secondary action at this time.

Choice B rationale

Assessing the fetal heart rate (FHR) immediately is the most critical intervention following rupture of membranes (ROM), especially when the fetal station is +1 (well-engaged). ROM increases the risk of cord prolapse, which can lead to acute fetal hypoxia and death. Continuous or frequent FHR monitoring via external or internal methods is essential to detect any signs of distress or umbilical cord compression.

Choice C rationale

Repositioning the client onto their left side (or right side) is a standard intervention to optimize uterine perfusion and placental blood flow when fetal heart rate (FHR) decelerations or non-reassuring patterns are observed. While beneficial, the initial priority is determining the fetal status after the membranes have ruptured by assessing the FHR before implementing general interventions like repositioning.

Choice D rationale

Determining the client's gestational age is important for overall management but does not address the immediate risk posed by the ruptured membranes in the setting of active labor (7 cm dilation). Fetal well-being assessment (FHR monitoring) takes precedence over gathering historical data, as it is a direct life-saving measure in this acute phase of labor with ruptured membranes.

Choice A rationale

Contractions occurring occasionally and lasting for 30 seconds every 2 minutes still represent a persistent pattern of uterine activity. The primary goal of tocolytic therapy is to inhibit or suppress uterine contractions in preterm labor. Therefore, contractions occurring every two minutes, even if occasional and short, do not fully demonstrate the desired outcome of effectively stopping or significantly spacing out the labor process.

Choice B rationale

A Fetal Heart Rate (FHR) of 170 bpm is a concerning fetal tachycardia (normal range is 110-160 bpm). Additionally, a decrease from moderate to minimal variability indicates a reduction in the healthy push-pull of the fetal autonomic nervous system, suggesting potential fetal distress or compromise. Neither fetal tachycardia nor decreased variability is a desired outcome from tocolytic therapy, which aims to improve the fetal environment.

Choice C rationale

A FHR of 140 bpm is within the normal range, but minimal variability suggests reduced fetal reserve or a drug effect, and the presence of late decelerations is a non-reassuring sign, indicative of uteroplacental insufficiency (a drop in FHR after the peak of a contraction). These findings collectively suggest fetal compromise and are not a desired outcome after initiating a tocolytic medication intended to prolong gestation.

Choice D rationale

Contractions slowing is the direct desired therapeutic effect of tocolytic agents like magnesium sulfate or nifedipine, as it prevents preterm birth. A fetal heart rate of 130 bpm is within the normal range (110-160 bpm), and moderate variability (6 to 25 beats per minute amplitude) is the most favorable and reassuring sign of adequate fetal oxygenation and a healthy central nervous system. This combination reflects a stable maternal-fetal status. .