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?
Observation of a sudden gush of amniotic fluid.
Hypotension with a blood pressure of 85/40 mm Hg.
Severe bradypnea with a respiratory rate of 10/min.
Palpation of the fetal presenting part in the cervical os.
The Correct Answer is B
Choice A rationale
A sudden gush of amniotic fluid typically indicates rupture of membranes (ROM), which can be spontaneous or induced. While ROM can occur during labor, it is not a direct indicator of uterine rupture, which is a catastrophic event involving the tearing of the uterine wall and often presents with different clinical signs.
Choice B rationale
Hypotension with a blood pressure of 85/40 mm Hg is a critical finding suggesting hypovolemic shock, often due to internal hemorrhage, which is a common consequence of uterine rupture. The sudden loss of maternal blood into the abdominal cavity leads to a rapid decrease in circulating blood volume and subsequent systemic hypotension.
Choice C rationale
Severe bradypnea with a respiratory rate of 10/min is not a primary indicator of uterine rupture. Bradypnea often suggests central nervous system depression, possibly from medication effects or other neurological events, but is not a direct physiological response to the acute blood loss and pain associated with a uterine tear.
Choice D rationale
Palpation of the fetal presenting part in the cervical os is a normal finding during labor progression as the fetus descends. However, if the presenting part is palpated higher or outside the uterus, it can indicate expulsion of the fetus into the abdominal cavity following a complete uterine rupture, which is an abnormal and emergent finding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Diphtheria-acellular pertussis (Tdap) vaccine is recommended for pregnant clients during the third trimester, specifically between 27 and 36 weeks of gestation. This timing optimizes the transfer of maternal antibodies to the fetus, providing passive immunity against pertussis (whooping cough) in the newborn during their vulnerable early months, before they are old enough to receive their own vaccinations.
Choice B rationale
Inactivated influenza vaccine is highly recommended for pregnant clients during any trimester of pregnancy. Pregnancy alters the immune system, making pregnant individuals more susceptible to severe complications from influenza. Vaccination protects both the mother and, through passive antibody transfer, the newborn from influenza infection.
Choice C rationale
Varicella vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection. While the actual risk is very low, it is generally deferred until the postpartum period. Women of childbearing age should be screened for immunity and vaccinated if non-immune prior to conception or postpartum.
Choice D rationale
Measles, mumps, and rubella (MMR) vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection, particularly with rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, causing severe birth defects. Vaccination should occur before conception or postpartum.
Choice E rationale
Human papillomavirus (HPV) vaccine is not routinely recommended during pregnancy. While current data do not suggest harm, the vaccine has not been extensively studied in pregnant individuals. Vaccination should be completed before pregnancy or deferred until the postpartum period.
Correct Answer is C
Explanation
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.
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