When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture?
A) Meconium-stained amniotic fluid
B) Fetus presenting in an LOA position
C) Maternal pulse of 90 to 95 beats/min
D) Blood-tinged vaginal discharge at full dilation
A
Feedback:
Meconium staining means that the fetus has lost rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. The fetal presentation is not assessed during membrane rupture. The maternal pulse rate of 90 to 95 beats/min is expected during labor. Blood-tinged vaginal discharge at full dilation is an expected finding.
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