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 A
Explanation
A. Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy that helps improve digestion and absorption of fats and proteins in individuals with cystic fibrosis. This treatment is especially important for those with pancreatic insufficiency, as it helps prevent the steatorrhea (fatty stools) commonly seen in these patients.
B. Decreased sodium excretion is incorrect. Pancrelipase does not directly affect sodium balance in the body. Cystic fibrosis patients may experience increased sodium excretion, which requires special management of fluid and electrolytes.
C. Improved respiratory function is incorrect. While pancrelipase improves digestion, it does not directly affect respiratory function, which is primarily impacted by the progressive lung disease in cystic fibrosis.
D. Improved absorption of vitamins B and C is incorrect. While pancrelipase helps with fat absorption, it primarily improves the absorption of fat-soluble vitamins (A, D, E, K) rather than water-soluble vitamins like B and C.
Correct Answer is B
Explanation
A. "Your baby needs to suck on a pacifier" is not necessarily the best advice for this situation. While pacifiers can help some babies self-soothe, crying is often a sign of an unmet need, and further assessment is needed to determine the cause of the crying. Offering a pacifier without addressing other potential causes might overlook the root issue.
B. "Swaddling your baby snugly in a blanket might help soothe her" is correct. Swaddling can help calm a newborn by providing a sense of security and warmth, mimicking the conditions of the womb. It is a common technique used to soothe babies.
C. "Breastfed babies are usually fussy from swallowing too much air during feedings" is incorrect. While some babies may have mild gas or discomfort from swallowing air, excessive crying is not typically due to this alone, especially if the baby has been fed properly and burped.
D. "Breastfed babies often need to be supplemented with formula" is not appropriate. While some breastfeeding difficulties can occur, advising formula supplementation without further investigation could undermine the breastfeeding process and should only be suggested after careful assessment and if truly necessary.
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