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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Eat 40 milligrams of protein-rich foods per day.": Protein intake is important during pregnancy, but 40 milligrams is an unusually low amount. The recommended amount is generally higher, around 71 grams of protein per day during pregnancy.
B. "Increase your dietary intake by 500 calories per day.": The general recommendation for calorie increase during pregnancy is about 300 calories per day, not 500. 500 calories per day may be recommended in specific situations, but it is not the typical guideline.
C. "Consume 600 micrograms of folic acid per day.": This is the correct recommendation. The CDC and other health guidelines recommend that pregnant individuals consume 400-600 micrograms of folic acid daily to prevent neural tube defects.
D. "Limit your caffeine intake to 700 milligrams per day.": Caffeine intake should generally be limited to around 200-300 milligrams per day during pregnancy, not 700 milligrams, as high caffeine intake can have adverse effects on pregnancy outcomes.
Correct Answer is C
Explanation
A. “I will follow a full-liquid diet the day before the procedure.": This is incorrect. Typically, clients are instructed to follow a clear-liquid diet the day before a colonoscopy, not a full-liquid diet. Clear liquids (e.g., water, broth, clear juices) are required to ensure the colon is fully cleaned out for the procedure.
B. “This procedure will take place while I'm under general anesthesia.”: This is incorrect. A colonoscopy is usually performed with moderate sedation or conscious sedation, not general anesthesia. The client may be sedated but will not be completely unconscious.
C. “I have my friend drive me home after the procedure.”: This is correct. After a colonoscopy, the sedation used for the procedure can impair the client's ability to drive. It is recommended that the client arrange for a friend or family member to drive them home.
D. “I can expect rectal bleeding for a week after the procedure.”: This is incorrect. Mild rectal bleeding can occur immediately after the procedure, but it should not last for a week. If bleeding persists beyond a day or two, the client should contact their healthcare provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.