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 C
Explanation
Answer: C. "You must be feeling scared and powerless."
Rationale:
A. "We have a neonatal unit here that's equipped to handle emergencies.
This response provides factual information but fails to acknowledge the client's emotional distress. While it may offer some reassurance, it does not directly validate the client's fears or foster therapeutic communication.
B. "Your pregnancy is advanced so your baby should be fine."
This statement offers premature reassurance without addressing the client’s emotional needs. It overlooks the potential risks of preterm birth at 32 weeks and may give a false sense of security, which could undermine trust if complications arise.
C. "You must be feeling scared and powerless."
This response reflects therapeutic communication by acknowledging the client’s emotional experience. It invites further discussion, demonstrates empathy, and builds a trusting relationship, which is essential during high-stress situations like preterm labor.
D. "Everyone worries about her baby when she's in labor."
This generalization minimizes the client’s individual feelings. It may make the client feel dismissed or that her concerns are not unique or important, which can hinder open, supportive communication.
Correct Answer is C
Explanation
A. Pattern of contractions: While the pattern of contractions can be an indicator of labor, it is not a definitive sign of true labor. True labor contractions typically become longer, stronger, and closer together over time. They also often follow a consistent pattern, with regular intervals between contractions. However, the pattern of contractions alone may not differentiate between true labor and false labor (Braxton Hicks contractions). False labor contractions tend to be irregular and do not cause significant cervical changes.
B. Rupture of the membranes: Rupture of the membranes, also known as the "breaking of the water," is another sign that labor may be imminent. However, it is not exclusive to true labor. Rupture of the membranes can occur before the onset of labor (premature rupture of membranes, PROM), during early labor, or even later in the active phase of labor. While it is an important event in the labor process, it alone does not confirm the onset of true labor.
C. Changes in the cervix: Changes in the cervix are a definitive sign of true labor. During true labor, the cervix begins to efface (thin out) and dilate (open) in preparation for childbirth. Cervical changes can be assessed through a pelvic examination, where the healthcare provider evaluates the degree of cervical effacement (thinning) and dilation (opening). Effacement and dilation of the cervix are indicative of true labor, suggesting that the body is actively progressing toward childbirth. This is considered one of the most reliable signs of labor onset.
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