A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?
Assess the fetal heart rate pattern.
Observe color and consistency of fluid.
Assess the client's temperature.
Evaluate client for the presence of chills and increased uterine tenderness using palpation.
The Correct Answer is A
A. Assess the fetal heart rate pattern: Following an amniotomy, the priority nursing action is to assess the fetal heart rate pattern. This procedure involves rupturing the amniotic sac, which can result in changes in fetal heart rate and may indicate fetal distress. Monitoring the fetal heart rate immediately after the procedure allows the nurse to detect any signs of fetal compromise and initiate prompt interventions if necessary.
B. Observe color and consistency of fluid: While assessing the color and consistency of the amniotic fluid is an essential nursing action after an amniotomy, it is not the priority. The priority is to ensure the well-being of the fetus by monitoring the fetal heart rate for any signs of distress.
C. Assess the client's temperature: While monitoring the client's temperature is important for detecting signs of infection following an amniotomy, it is not the priority immediately after the procedure. Assessing the fetal heart rate takes precedence to ensure the fetal well-being.
D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation: While assessing for signs of infection, such as chills and increased uterine tenderness, is important after an amniotomy, it is not the priority. Monitoring the fetal heart rate is the priority to detect any signs of fetal distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Assist the client to the bathroom to void:
A slightly boggy and displaced fundus to the right suggests a full bladder. A full bladder can displace the uterus and interfere with uterine contractions, leading to uterine atony. Therefore, the nurse should assist the client to the bathroom to void. Emptying the bladder will help the uterus to contract properly and return to its midline position.
A) Ask the client to rate her pain:
Pain assessment is important for overall client care but is not the priority in this situation. The displacement of the fundus suggests a physiological issue rather than pain being the primary concern.
C) Encourage the client to move to the left lateral position:
While positioning can assist with uterine displacement in some cases, the priority action is to address the full bladder. Once the client has emptied her bladder, the nurse can encourage a left lateral position to help optimize uterine contraction.
D) Encourage the client to perform Kegel exercises:
Kegel exercises are not indicated for addressing a boggy and displaced fundus. These exercises are typically used to strengthen the pelvic floor muscles, which can help with urinary incontinence and promote healing postpartum. However, they will not directly address the issue of a displaced fundus caused by a full bladder.
Correct Answer is ["175.0"]
Explanation
Here's how we can find the amount of cephazolin the nurse should administer per dose:
Convert weight to kilograms: The infant's weight is given in grams (g). Since dosage is typically prescribed per kilogram (kg), we need to convert the weight:
Weight (kg) = Weight (g) / 1000
Weight (kg) = 3500 g / 1000 = 3.5 kg
Calculate total dosage per day: The infant is prescribed 50 mg of cephazolin per kilogram of body weight per dose, and the medication is given three times a day. Therefore, to find the total milligrams per dose, we can multiply the dosage by the infant's weight:
Total dosage per dose (mg) = Dosage (mg/kg) * Weight (kg)
Total dosage per dose (mg) = 50 mg/kg * 3.5 kg = 175 mg
Therefore, the nurse should administer 175.0 milligrams of cephazolin per dose, rounded to the nearest tenth.
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