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. Nausea and vomiting: Nausea and vomiting can be present with hypernatremia (high sodium levels), but they are not the most prominent or specific symptom. The client may experience these symptoms, but they are usually accompanied by other signs.
B. Altered mental status: This is a common manifestation of hypernatremia. The elevated sodium level causes an osmotic imbalance, leading to water shifting out of cells, which results in neurological symptoms, including confusion, lethargy, or seizures.
C. Dysrhythmias: Dysrhythmias can occur with electrolyte imbalances, including hypernatremia, but the primary symptoms related to sodium levels are more often neurological in nature, such as confusion or altered mental status, rather than dysrhythmias specifically.
D. Hypothermia: Hypernatremia typically causes an increase in body temperature, not hypothermia. Elevated sodium levels cause dehydration, which could contribute to increased body temperature rather than cooling.
Correct Answer is B
Explanation
A. Instant coffee: Instant coffee generally contains more caffeine than brewed green tea or cola soft drinks. A typical 8 oz serving of instant coffee contains about 30–90 mg of caffeine.
B. Hot cocoa: This is correct. Hot cocoa contains the least amount of caffeine compared to the other options. An 8 oz serving typically contains around 5–10 mg of caffeine.
C. Brewed green tea: Brewed green tea typically contains more caffeine than hot cocoa, with an 8 oz serving containing around 30–50 mg of caffeine.
D. Cola soft drink: Cola soft drinks typically contain more caffeine than hot cocoa, with an 8 oz serving containing about 24–46 mg of caffeine.
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