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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Variable decelerations.
A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.
B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.
C. Late decelerations are indicative of uteroplacental insufficiency.
Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.
D. Variable decelerations are associated with umbilical cord compression.
Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.
Correct Answer is B
Explanation
The correct answer is B. Massage the client's back.
A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.
B. Massage the client's back is consistent with the gate control theory of pain.
According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.
C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.
D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today