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 B

Explanation

Choice A Reason:

Active is incorrect. The active phase of labor typically begins when the cervix is around 4 to 6 centimeters dilated. Given that the client's cervix is already dilated to 9 cm, she has progressed beyond the active phase.

Choice B Reason:

Transition is correct. The transition phase is the final part of the first stage of labor and occurs when the cervix is dilated from 8 to 10 centimeters. In this phase, contractions are typically strong, occurring every 2 to 3 minutes, and lasting 80 to 90 seconds. The sensation of increasing rectal pressure is common during the transition phase as the baby's head descends further into the birth canal. The advanced cervical dilation to 9 cm also indicates that the client is in the transition phase, preparing for the second stage of labor.

Choice C Reason:

Latent is incorrect. The latent phase is the early part of the first stage of labor, characterized by cervical dilation from 0 to 3 or 4 centimeters. The client's cervix is already dilated to 9 cm, indicating that she has progressed well beyond the latent phase.

Choice D Reason:

Descent is incorrect. The descent phase is generally associated with the second stage of labor, during which the baby moves through the birth canal. The information provided primarily relates to the first stage of labor, specifically the transition phase, as indicated by the cervical dilation of 9 cm.

A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness

Correct Answer is A

Explanation

The correct answer is A.

A. Shortness of breath: Shortness of breath can be a serious side effect of combined oral contraceptives (COCs) and may indicate a potential risk of a blood clot or other cardiovascular issues. It is crucial for the client to seek medical attention promptly if experiencing shortness of breath.

B. Breakthrough bleeding: Breakthrough bleeding is a common side effect of COCs, especially during the first few months of use. While it can be bothersome, it is generally not considered a serious adverse effect. However, the healthcare provider may need to adjust the dosage or type of contraceptive if breakthrough bleeding persists.

C. Vomiting: Vomiting can decrease the absorption of COCs, and if vomiting occurs within a few hours after taking the pill, a backup form of contraception may be needed. However, it is not necessarily an adverse effect that requires immediate notification unless it leads to an inability to take the medication consistently.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives and is generally not considered a serious adverse effect. Clients are often advised to monitor for changes in breast tenderness, but it does not require immediate notification.

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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

Correct Answer is B

Explanation

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects which of the following findings should the nurse instruct the client to notify the provider? of the medication For

Correct Answer is A

Explanation

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