A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Prepare equipment needed for newborn resuscitation

Perform endotracheal suctioning as soon as the fetal head is delivered

Prepare the client for an ultrasound examination

Prepare the client for an emergency cesarean birth

Answer and Explanation

The Correct Answer is A

A. Prepare equipment needed for newborn resuscitation.

A. Preparing equipment needed for newborn resuscitation is the correct action.

Meconium-stained amniotic fluid can increase the risk of meconium aspiration syndrome in the newborn. While the fetal heart rate is reassuring, being prepared for potential newborn resuscitation is prudent given the meconium staining.

B. Performing endotracheal suctioning as soon as the fetal head is delivered is not the current standard of care. The American Academy of Pediatrics (AAP) no longer recommends routine suctioning of meconium-stained infants unless they show signs of respiratory distress, poor muscle tone, or a depressed heart rate.

C. Preparing the client for an ultrasound examination is not the immediate priority. Meconium-stained amniotic fluid may be associated with fetal distress, but the focus should be on the current labor and delivery situation.

D. Preparing the client for an emergency cesarean birth is not the first action.

The presence of meconium staining alone does not necessarily indicate the need for an emergency cesarean birth, especially if the fetal heart rate is reassuring.

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Correct Answer is C

Explanation

The correct answer is C. Continuous contraction lasting 2 min.

A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.

B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.

C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.

A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.

D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.

A. Increased fetal movement B. Leakage of fluid from the vagina C. Upper abdominal discomfort D. Urinary frequency

Correct Answer is B

Explanation

The correct answer is B.

A. Increased fetal movement: Increased fetal movement is generally not considered a complication after an amniocentesis. Fetal movement is a positive sign, indicating fetal well-being. However, it's important to monitor for any changes in movement patterns.

B. Leakage of fluid from the vagina: Leakage of amniotic fluid from the vagina is a potential complication after amniocentesis. It may indicate rupture of the amniotic sac, which can lead to preterm labor and other complications. This finding should be reported promptly to the healthcare provider.

C. Upper abdominal discomfort: Mild upper abdominal discomfort can occur after an amniocentesis, but it is not typically a severe complication. It may be related to the procedure itself and often resolves with rest. However, persistent or severe discomfort should be reported.

D. Urinary frequency: Urinary frequency is not typically associated with complications after an amniocentesis. It may be a normal symptom related to the position of the uterus or other factors, but it does not generally warrant immediate reporting as a complication.

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A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Nursing Test Bank

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