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.
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Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Place the client in a knee-chest or Trendelenburg position.
Choice A rationale:
Preparing the client for an emergency cesarean birth is important, but it is not the immediate first action. The priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.
Choice B rationale:
Explaining to the client what is happening is important for communication and reassurance, but it is not the immediate first action. Immediate physical intervention is required to prevent harm to the fetus.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is a necessary step to prevent the cord from drying out and to reduce infection risk, but it should be done after repositioning the client to relieve pressure on the cord.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position helps to relieve pressure on the umbilical cord, which is crucial to maintain fetal oxygenation. This is the immediate first action to take in this emergency situation.
Correct Answer is C
Explanation
Choice A rationale:
Preterm labor. Performing a pelvic examination in a client with placenta previa can potentially trigger uterine contractions, leading to preterm labor. Manipulating the cervix during the examination may stimulate the release of hormones that could initiate labor, putting both the mother and the baby at risk.
Choice B rationale:
Infection. While infection is a valid concern in any medical procedure, it is not the primary rationale for avoiding a pelvic examination in a client with placenta previa. The primary concern is the risk of severe bleeding caused by the disruption of the placenta's attachment to the uterine wall.
Choice C rationale:
Profound bleeding. The primary rationale to avoid a pelvic examination in a client with placenta previa is the risk of profound bleeding. Placenta previa occurs when the placenta covers part or all of the cervix, and it is at risk of being damaged or detached during a pelvic exam. This can lead to life-threatening hemorrhage for both the mother and the baby.
Choice D rationale:
Rupture of the fetal membranes. While this complication is possible during a pelvic examination, it is not the primary rationale to avoid the procedure in a client with placenta previa. The main concern, as mentioned before, is the risk of severe bleeding that can occur due to placental disruption.
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