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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 C

Explanation

A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.

B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.

C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.

D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.

A. Leave noninvasive equipment on the client's body. B. Remove the client's dentures. C. Turn the lights up in the client's room. D. Close the client's eyes before the family views the body.

Correct Answer is B

Explanation

A. Leave noninvasive equipment on the client's body. This is incorrect. Noninvasive equipment, such as oxygen tubing or blood pressure cuffs, should be removed before the family views the body to allow for a respectful presentation of the deceased.

B. Remove the client's dentures. This is the correct action. Dentures should be removed after death to preserve the appearance of the face. They should be cleaned and placed with the client’s belongings.

C. Turn the lights up in the client's room. This is not recommended. The lights should generally be dimmed to create a more peaceful and respectful environment for family members.

D. Close the client's eyes before the family views the body. While it is respectful to close the client’s eyes, this action should only be taken if the family has not yet viewed the body. If the family wishes to see the deceased with their eyes open, the nurse should respect that preference.

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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 caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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