Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
Vital Signs2000:
Temperature 36.7┬░ C (98.1┬░ F).
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours ago and is a greenish color." Client also reports contractions began about 4 hr ago and have become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad. Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min. Vaginal examination performed: cervix 4 cm dilated, 70% effaced, O station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
A nurse in an antepartum unit is caring for a client.Exhibits Select the 2 findings that require immediate follow-up.
Correct answer
B,D
Rationale
The correct answers are B (Fetal heart rate) and D (Characteristics of amniotic fluid) because these findings are critical indicators of fetal well-being. Changes in fetal heart rate may indicate fetal distress, requiring immediate intervention. Monitoring amniotic fluid characteristics is crucial to assess for potential complications like infection or rupture. Blood pressure, fetal station, and contraction duration are important but not as urgent as fetal heart rate and amniotic fluid assessment in this context.