Which of the following findings indicates a client who is in a trial of labor for vaginal birth after cesarean (VBAC) may be experiencing a uterine rupture?

Choice A reason: Palpation of the fetal presenting part in the cervical os indicates labor progression or malpresentation, not uterine rupture. Uterine rupture involves uterine wall tearing, causing hemorrhage or fetal extrusion, not cervical findings. This finding is unrelated to the catastrophic internal bleeding or placental disruption characteristic of rupture.

Choice B reason: Severe bradypnea (respiratory rate of 10/min) is not a primary sign of uterine rupture. Rupture causes hemorrhage, leading to hypovolemic shock with symptoms like hypotension or tachycardia. Respiratory changes may occur secondary to shock but are not specific. Uterine rupture primarily affects cardiovascular stability, not respiratory rate.

Choice C reason: A sudden gush of amniotic fluid indicates membrane rupture, a normal labor event, not uterine rupture. Uterine rupture involves uterine wall tearing, causing bleeding or fetal distress, not fluid release. Amniotic fluid loss is unrelated to the structural failure or hemorrhagic shock associated with uterine rupture in VBAC.

Choice D reason: Hypotension (85/40 mm Hg) indicates uterine rupture, as it suggests hypovolemic shock from internal hemorrhage due to uterine wall tearing. Blood loss reduces intravascular volume, impairing cardiac output and placental perfusion. This life-threatening sign in VBAC requires immediate intervention to address maternal and fetal compromise, aligning with rupture’s pathophysiology.

Choice A reason: Obtaining the client’s temperature, heart rate, and blood pressure assesses maternal status but is not the highest priority. Nausea and an urgent need for a bowel movement suggest advanced labor or fetal head compression. Fetal heart rate (FHR) monitoring is critical, as strong contractions may reduce placental perfusion, risking fetal hypoxia, which takes precedence over maternal vital signs to ensure immediate fetal safety.

Choice B reason: Examining vaginal discharge for meconium indicates potential fetal stress but is not the highest priority. Nausea and bowel urgency suggest rapid labor progression or fetal head compression, impacting FHR. Assessing FHR first ensures fetal oxygenation status, as meconium is a secondary finding that does not immediately guide interventions for acute distress during strong contractions.

Choice C reason: Determining the fetal heart rate in relationship to contractions is the highest priority, as nausea and bowel urgency indicate possible second-stage labor or fetal head compression, causing FHR decelerations. Strong contractions may reduce placental blood flow, risking hypoxia. Continuous monitoring via scalp electrode detects late or variable decelerations, guiding urgent interventions to ensure fetal safety.

Choice D reason: Performing a sterile vaginal examination assesses labor progress but is not the highest priority. Nausea and bowel urgency suggest advanced labor, but FHR assessment takes precedence to rule out fetal distress. Vaginal exams risk infection or membrane rupture and do not directly address fetal oxygenation, critical during strong contractions that may compromise placental perfusion.