A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?
Evaluate the client for signs of infection.
Check the fetal heart rate pattern.
Observe the color and consistency of amniotic fluid.
Take the client's temperature.
The Correct Answer is B
Choice A rationale:
The priority nursing action after an amniotomy is to ensure the well-being of both the mother and the baby. While evaluating the client for signs of infection is important, it is not the immediate priority. Infection can be a concern after any invasive procedure, but checking the fetal heart rate pattern takes precedence to assess the baby's condition immediately after the amniotomy.
Choice B rationale:
Checking the fetal heart rate pattern is the priority because it helps to monitor the baby's well-being and detect any signs of fetal distress. Amniotomy is the artificial rupture of the amniotic membrane, and it can sometimes lead to changes in the baby's heart rate, which may indicate distress or other complications. Identifying and addressing these changes
promptly is crucial for the baby's safety.
Choice C rationale:
Observing the color and consistency of amniotic fluid is essential to assess for any abnormalities or meconium staining, which could indicate fetal distress or potential issues. However, this action should follow the immediate concern of checking the fetal heart rate pattern since fetal distress takes priority over amniotic fluid characteristics.
Choice D rationale:
Taking the client's temperature is important, but it is not the priority immediately after an amniotomy. Monitoring the client's temperature is a routine nursing action to detect any signs of infection. However, the priority in this situation is to ensure the baby's well-being through fetal heart rate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Assist the client to breathe into a paper bag.
Choice A rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.
Choice B rationale:
Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.
Choice C rationale:
Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.
Choice D rationale:
Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.
Correct Answer is C
Explanation
Choice A rationale:
The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.
Choice B rationale:
The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.
Choice C rationale:
This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.
Choice D rationale:
The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.
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