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 C
Explanation
A. "I can prevent nausea if I take the medication on an empty stomach." This is incorrect. Taking ferrous sulfate on an empty stomach may increase the risk of gastrointestinal upset, including nausea. It is typically recommended to take it with food to reduce these side effects, although it may be less effective if taken with certain foods or beverages.
B. "I can prevent constipation if I drink more milk while taking this medication." This is incorrect. Milk can actually worsen constipation, and clients taking ferrous sulfate should focus on increasing fiber intake and drinking plenty of fluids to prevent constipation.
C. "I will report black stools to my doctor." This is correct. Black stools are a common side effect of iron supplementation, but it is essential for the client to report it to the doctor if they are concerned, as it could also indicate gastrointestinal bleeding in some cases.
D. "I will mix the medication with a full glass of water." While taking the medication with a full glass of water is appropriate, it is not the most significant instruction regarding the use of the medication. Therefore, while the answer isn't wrong, it doesn't indicate the client's understanding of the most important aspects, such as monitoring for side effects like black stools.
Correct Answer is B
Explanation
A. Removing personal protective equipment (PPE. after leaving the room is incorrect because it should always be done before leaving the client's room to ensure the nurse does not accidentally spread the infection. Proper removal of PPE is crucial to preventing transmission.
B. Wearing a gown when assisting the client with personal hygiene is correct. MRSA is typically spread through direct contact, so wearing a gown when providing personal care (e.g., assisting with hygiene. helps prevent the spread of MRSA. Additionally, gloves and other PPE should also be worn.
C. Negative air pressure is typically required for airborne precautions, such as for clients with tuberculosis, but not for MRSA, which is transmitted via contact. Therefore, this is not necessary for MRSA care.
D. Restricting the client's visitors is not necessary unless the client has an infection that requires isolation precautions beyond what is standard for MRSA. MRSA can be controlled with contact precautions, and visitor restrictions are generally not part of standard MRSA isolation.
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