QUESTION: "A 34-year-old multigravida at 36 weeks' gestation in active labor has been diagnosed with Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. The nurse explains to the client that this is usually due to which of the following?"
CHOICES
( O ) a.) Rh sensitization.
( X ) b.) Abnormal presentation.
( X ) c.) Amniotic fluid embolism.
( X ) d.) Oligohydramnios.
RATIONALE: Amniotic fluid is normally clear. Yellowish fluid indicates Rh sensitization. The yellowish color is related to fetal anemia and bilirubin in the amniotic fluid. In an abnormal presentation, in this case a breech presentation, it is not uncommon for the amniotic fluid to be green in color owing to meconium expelled by the fetus. Amniotic fluid embolism is not related to the fluid color. This condition, a medical emergency, may occur naturally after a difficult labor or from hyperstimulation of the uterus. Oligohydramnios refers to a markedly decreased volume of amniotic fluid. It has no association with the color of the fluid. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
