A nurse is assisting in the care of a client who is in labor.
The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to
mean which of the following?

 

Choice A rationale:

Rh positive individuals already have the Rh factor on their red blood cells, so they do not need Rho(D) immune globulin to

prevent sensitization.

The newborn being Rh positive does not pose a risk to an Rh positive mother, as their blood types are compatible.

Choice B rationale:

Rh positive individuals cannot develop antibodies against the Rh factor, as it is already present on their own red blood cells.

The newborn's Rh negative status does not create a risk of sensitization for the mother, as there is no Rh factor to trigger an

immune response.

Choice C rationale:

If both the mother and the newborn are Rh negative, there is no risk of Rh incompatibility.

This is because neither individual has the Rh factor on their red blood cells, so there is no potential for sensitization.

Choice D rationale:

When an Rh negative mother carries an Rh positive fetus, there is a risk of Rh sensitization during pregnancy and delivery.

This occurs when fetal blood cells cross the placenta and enter the mother's bloodstream, exposing her immune system to the

Rh factor.

If the mother's immune system recognizes the Rh factor as foreign, it can produce antibodies against it.

These antibodies can cross the placenta in subsequent pregnancies and attack the red blood cells of Rh positive fetuses,

leading to hemolytic disease of the newborn (HDN).

Rho(D) immune globulin is a medication that can prevent Rh sensitization by binding to Rh positive fetal blood cells that have

entered the mother's bloodstream.

This prevents the mother's immune system from recognizing the Rh factor and producing antibodies.

Rho(D) immune globulin is typically given to Rh negative mothers within 72 hours of delivery of an Rh positive newborn, as well as after other events that could lead to Rh sensitization, such as miscarriage, abortion, or ectopic pregnancy.

Choice A rationale:

Umbilical cord compression is the most common cause of variable decelerations. It occurs when the umbilical cord is

compressed, momentarily reducing blood flow to the fetus and causing a decrease in fetal heart rate.

Variable decelerations are characterized by their abrupt onset, variable duration, and unpredictable shape. They typically

recover quickly to the baseline fetal heart rate after the compression is relieved.

Several factors can contribute to umbilical cord compression, including:

Fetal movement: The fetus can sometimes move in a way that compresses the cord, especially during active labor.

Oligohydramnios (low amniotic fluid): With less amniotic fluid, there's less cushioning around the cord, making it more prone

to compression.

Nuchal cord (cord around the neck): If the cord is wrapped around the fetus's neck, it can become compressed during

contractions.

Short umbilical cord: A shorter cord has less slack, increasing the risk of compression.

Choice B rationale:

Maternal hypotension can cause fetal heart rate decelerations, but these typically present as late decelerations, not variable

decelerations. Late decelerations have a gradual onset, a uniform shape, and typically occur after the peak of a contraction.

Maternal hypotension can decrease placental blood flow, leading to fetal hypoxia (decreased oxygen supply). This hypoxia can

then trigger a decrease in fetal heart rate.

Choice C rationale:

The fetal sleep cycle does not typically cause variable decelerations in the fetal heart rate. During sleep, the fetal heart rate

may exhibit a decrease in baseline variability, but this is not the same as variable decelerations.

Choice D rationale:

The use of epidural anesthesia can sometimes cause a decrease in fetal heart rate variability, but it does not typically cause

variable decelerations. Epidural anesthesia can lead to maternal hypotension, which, as mentioned earlier, can cause late

decelerations.