A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)
Obtain a baseline reading of the FHR and contraction pattern.
Document the procedure in the electronic medical record.
Pass the sterile hook to the provider.
Position the client with a rolled towel under her hips
Check the fluid for color, odor, and consistency
The Correct Answer is A,D,C,E,B
- A. Obtain a baseline reading of the FHR and contraction pattern.
- Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
- D. Position the client with a rolled towel under her hips.
- Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
- C. Pass the sterile hook to the provider.
- The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
- E. Check the fluid for color, odor, and consistency.
- After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
- B. Document the procedure in the electronic medical record.
- The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.
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Related Questions
Correct Answer is B
Explanation
A. “This medication will darken the color of my eyes.” is incorrect. Timolol is a nonselective beta-blocker used to reduce intraocular pressure in glaucoma. It does not typically cause eye color changes.
B. "I should check my heart rate while taking this medication." is correct. Timolol can cause systemic side effects such as bradycardia, so the client should monitor their heart rate while taking the medication.
C. "I should take a zinc supplement while taking this medication." is incorrect. Zinc supplementation is not related to the use of timolol.
D. “This medication will dilate my eyes." is incorrect. Timolol works by decreasing aqueous humor production, reducing intraocular pressure, and does not cause dilation of the eyes. Medications like atropine are used for pupil dilation.
Correct Answer is C
Explanation
A. Medication: The medication, erythromycin, is appropriately prescribed. No clarification is needed regarding the medication.
B. Dosage: The prescribed dosage of 500 mg is a common dose for erythromycin, and there is no indication that it needs to be clarified.
C. Time: The prescription states that the medication is to be given four times per day, but the specific times (e.g., morning, noon, evening, bedtime. are not mentioned. The nurse should clarify the exact timing to ensure proper spacing of doses and avoid interactions.
D. Route: The route is typically oral for erythromycin, and there is no indication that clarification is needed.
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