A nurse is caring for a client who is in a trial of labor for vaginal birth after cesarean (VBAC). The client reports a sudden tearing pain in their back and side that does not feel like a uterine contraction.
Which of the following findings indicates the client may be experiencing a uterine rupture?

Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.

Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.

Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.

Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.

Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.

Choice A rationale

Administering a rubella immunization during pregnancy is contraindicated because the rubella vaccine is a live attenuated virus vaccine. There is a theoretical risk of viral transmission to the fetus, which could lead to congenital rubella syndrome. Vaccination should occur postpartum to protect future pregnancies.

Choice B rationale

Breastfeeding is not contraindicated after receiving the rubella vaccine. Although rubella vaccine virus can be excreted in breast milk, it generally does not cause clinical illness in the infant and passive transfer of antibodies may provide some protection to the infant.

Choice C rationale

A rubella titer of 1: indicates a low level of rubella antibodies, meaning the client is susceptible to rubella infection. A titer of less than 1: or 1: is generally considered non-immune, requiring vaccination to prevent congenital rubella syndrome in future pregnancies.

Choice D rationale

Repeating a rubella titer in the third trimester is not a standard practice for assessing susceptibility. Once susceptibility is determined, the primary intervention is postpartum vaccination. The initial titer result accurately reflects immune status and further testing during pregnancy is unnecessary.