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Client’s cervix is 3 cm dilated. Fetus is in a right occiput anterior cephalic position. External fetal heart rate and uterine contraction monitors on client’s abdomen. Fetal heart rate baseline is 125 beats/min with moderate variability and accelerations. Uterine contractions are occurring every 3 minutes. Client reporting minimal discomfort with contractions. Client’s partner is at bedside. Vital signs: temperature, 97.7°F (36.5°C); heart rate, 62 beats/min; respiratory rate, 16 breaths/min; blood pressure, 100/64 mm Hg. Oxygen saturation is 100% on room air. 1635 Client reports feeling a gush of fluid from the vagina. Fetal heart rate is 80 beats/min and variability is absent. Client alert, oriented, and tearful. Upon assessment, umbilical cord loop visible protruding from client’s vagina. Vital signs: temperature, 98.9°F (37.2°C); heart rate, 82 beats/min; respiratory rate, 18 breaths/min; blood pressure, 112/64 mm Hg. Oxygen saturation is 96% on room air. The nurse is reviewing the Nurse’s Notes from 1630 and 1635 with the health care provider. Which assessment finding(s) indicates to the nurse that the client’s condition has declined? Select all that apply. Change in fetal heart rate baseline Change in client’s oxygen saturation Umbilical cord loop coming out of client’s vagina Change in client’s temperature Change in
SCIENCE
HEALTH SCIENCE
NURSING

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