A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?
Take the mother’s vital signs every 15 minutes.
Send a specimen of the fluid to the laboratory for analysis.
Have a suction catheter available for use at delivery.
Prepare a slide of the fluid for fern testing.
The Correct Answer is C
The correct answer is choice C. Have a suction catheter available for use at delivery. This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia. Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.
Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.
Vital signs should be monitored regularly during labor regardless of the fluid color.
Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.
The laboratory analysis will not change the immediate management of the newborn.
Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.
Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
Correct Answer is C
Explanation
The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.
This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.
The duration is measured from the start of one contraction until the end of that same contraction.
Choice A is wrong because it measures the frequency of contractions, not the duration.
The frequency is the time between the start of one contraction and the start of the next one.
Choice B is wrong because it measures only half of the duration of a contraction.
The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.
Choice D is wrong because it measures both the duration and the interval of contractions.
The interval is the time between the end of one contraction and the start of the next one.
Normal ranges for contractions during labor are:
• Duration: 30 to 90 seconds
• Frequency: 2 to 5 minutes apart
• Interval: 30 to 120 seconds
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