A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

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 is38°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.

Choice A Reason:
"The nurse will carry your newborn to the nursery for procedures. "This statement is inappropriate. In current practice, there is an emphasis on family-centered care, and parents are often encouraged to be involved in the care of their newborns, including accompanying them for procedures whenever possible.

Choice B Reason:
"We will document the relationship of visitors in your medical record." This statement is inappropriate. While it is important to monitor and document visitors, the primary focus here is on healthcare staff and their identification.

Choice C Reason:
"Your baby will stay in the nursery while you are asleep." This statement is inappropriate. Promoting rooming-in and encouraging parental involvement in newborn care is a common practice to support bonding and breastfeeding, so this statement may not align with current best practices.

Choice D Reason:
"Staff members who take care of your baby will be wearing a photo identification badge." This statement reassures the client that the healthcare providers involved in the care of the newborn will have proper identification, enhancing security and ensuring that authorized personnel are handling the infant.