A DDA nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

O2 saturation

Temperature

Blood pressure

Urinary output

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature: Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is 38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes. The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.

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Correct Answer is C

Explanation

Choice A Reason:

Percutaneous umbilical blood sampling (PUBS) is not appropriate. This invasive procedure involves sampling blood from the umbilical cord and is not typically used in the context of a positive contraction stress test.

Choice B Reason:

Amnioinfusion is not appropriate. Amnioinfusion is a procedure in which sterile fluid is infused into the amniotic cavity to alleviate conditions such as oligohydramnios. It is not a primary diagnostic test for assessing fetal well-being.

Choice C Reason:

Biophysical profile (BPP) is appropriate. The biophysical profile is a diagnostic test that assesses the well-being of the fetus by evaluating various parameters, including fetal heart rate, fetal breathing movements, fetal movements, fetal tone, and the amniotic fluid volume. This test provides additional information to assess fetal well-being and can help guide decisions about the timing and mode of delivery.

Choice D Reason:

Chorionic villus sampling (CVS) is inappropriate. CVS is a prenatal test used for diagnosing certain genetic conditions but is not indicated in the context of a positive contraction stress test.

A. Respiratory depression B. Tachycardia C. Hypotension D. Vomiting

Correct Answer is C

Explanation

The correct answer is C. Hypotension.

A. Respiratory depression is not a common complication of epidural anesthesia. It is more associated with opioid analgesics or excessive administration of other anesthetics.

B. Tachycardia is generally not associated with epidural anesthesia. It is more commonly observed in response to pain or anxiety.

C. Hypotension is a common complication of epidural anesthesia.

Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. This is particularly common when the block is administered rapidly or with a higher dose.

D. Vomiting is not a direct complication of epidural anesthesia. Nausea and vomiting are more commonly associated with opioid analgesics or general anesthesia.

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A DDA nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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