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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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

A. "I will make sure that electrical wires are run under carpeting." B. "I will have the heating system inspected once every 3 years." C. "I will have my hearing tested every 2 years." D. "I will make sure that my hot water faucets are color-coded."

Correct Answer is D

Explanation

A. "I will make sure that electrical wires are run under carpeting.": This is not a safe practice. Running electrical wires under carpeting can lead to the wires overheating or becoming damaged, which is a fire hazard.

B. "I will have the heating system inspected once every 3 years.": The heating system should be inspected more frequently than every three years, ideally annually, to ensure safety and proper functioning.

C. "I will have my hearing tested every 2 years.": While hearing should be monitored regularly, this is not a specific home safety measure. A hearing impairment can increase the risk of falls or accidents.

D. "I will make sure that my hot water faucets are color-coded.": This is an important safety measure, particularly for older adults, as it helps prevent burns. Color-coded faucets can help prevent the risk of hot water burns by easily identifying hot and cold water.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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