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, C, D, A

Explanation

B. Palpate the fundus to identify the fetal part. This step helps determine which part of the fetus is in the upper part of the uterus (fundus), usually the head or buttocks. C. Determine the location of the fetal back. This step involves palpating the sides of the abdomen to locate the fetal back, which feels firm and smooth, and the small parts (limbs), which feel irregular and knobby. D. Palpate for the fetal part presenting at the inlet. This step helps identify the part of the fetus that is above the pelvic inlet, usually the head or buttocks. A. Identify the attitude of the head. This final step involves determining the position and attitude of the fetal head,which helps assess the degree of flexion or extension.

A. "You can miss your period for several other reasons. Describe your typical menstrual cycle B. "If you have been sexually active and haven't used protection it is likely that you are pregnant C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet? D. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying

Correct Answer is A

Explanation

Choice A Reason:

"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.

Choice B Reason:

"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.

Choice C Reason:

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.

Choice D Reason:

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.

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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

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