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.

Answer and Explanation

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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Correct Answer is ["A","D","E"]

Explanation

Dysuria - Dysuria refers to painful or difficult urination. In a client with a urinary tract infection (UTI), this symptom is commonly present. The rationale behind this finding is that the infection irritates the urinary tract, causing discomfort and pain during urination. The client may experience a burning sensation or pressure while passing urine.

Choice D rationale

Hematuria - Hematuria refers to the presence of blood in the urine. In the case of a UTI, inflammation of the urinary tract can lead to tiny blood vessels rupturing, resulting in blood in the urine. This can cause the urine to appear pink, red, or brownish.

Choice E rationale:

Urinary frequency - Urinary frequency is another common symptom of a UTI. The infection can irritate the bladder lining, leading to an increased urge to urinate even when the bladder is not full. The client may feel the need to urinate frequently throughout the day and night.

Choice B rationale

Dependent edema - Dependent edema is not typically associated with a urinary tract infection. Edema is the accumulation of fluid in tissues, often causing swelling in the lower extremities due to gravity (dependent). This symptom is more commonly related to issues such as heart, kidney, or liver problems.

Choice C rationale

Polyuria - Polyuria refers to excessive urination, usually producing abnormally large volumes of urine. While frequent urination is a symptom of a UTI, polyuria, in this context, is not accurate. UTIs tend to cause frequent but smaller volumes of urine due to the irritation and inflammation of the bladder.

A. Severe nausea and vomiting. B. Pelvic pain. C. Uterine enlargement greater than expected for gestational age. D. Copious vaginal bleeding.

Correct Answer is B

Explanation

Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.

Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.

Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.

Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.

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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?

Nursing Test Bank

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Explanation

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Explanation

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