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.

Answer and Explanation

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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Correct Answer is ["B","D","E"]

Explanation

B) "I will resume taking my prenatal vitamins."
Resuming prenatal vitamins is important for postpartum recovery, as they can help replenish essential nutrients, especially if the client is breastfeeding.

D) "I should not have unrelieved pain in my abdomen."
This statement indicates that the client understands the importance of managing pain effectively after a cesarean birth. Unrelieved pain could be a sign of complications and should be reported to the healthcare provider.

E) "I will call my provider if I have discharge from my incision."
This statement demonstrates the client's understanding of the importance of monitoring the incision for signs of infection. Any discharge from the incision should be reported to the healthcare provider promptly.

A) "I am likely to have a fever during the first week I am home."
While a low-grade fever in the immediate postoperative period is not unusual, it should be reported if it persists or worsens. It's not appropriate to assume having a fever is a typical part of the recovery process.

C) "I will rest in a recliner until my incision is healed."
It's important for the client to rest, but recliners may not provide adequate support for the incision. It's generally recommended to rest in a bed with proper back support to aid in the recovery process.

A. "There is an increased risk of rupture of the membranes. B. "There is an increased risk of introducing infection." C. "This could initiate preterm labor." D. "This could result in profound bleeding."

Correct Answer is D

Explanation

A) "There is an increased risk of rupture of the membranes": While there is a risk of premature rupture of membranes with placenta previa, the primary reason for avoiding internal examinations is the potential for profound bleeding. Internal examinations can dislodge the placenta, leading to significant hemorrhage, rather than directly causing rupture of the membranes.

B) "There is an increased risk of introducing infection": While infection is a concern with any internal procedure, the primary reason for avoiding internal examinations in placenta previa is the risk of provoking bleeding.

C) "This could initiate preterm labor": Internal examinations in placenta previa are not typically associated with initiating preterm labor. The primary concern is the risk of significant bleeding due to disruption of the placenta.

D) "This could result in profound bleeding": This is the correct explanation. Performing internal examinations in placenta previa increases the risk of dislodging the placenta, leading to severe bleeding. Avoiding unnecessary internal examinations helps minimize this risk and promotes the safety of both the mother and the baby.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is D

Explanation

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