A nurse is assisting with the care of a client.

Vital Signs.

1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.

Respiratory rate 16/min.

Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.

Temperature 37 °C (98.6 °F) Heart rate 112/min.

Respiratory rate 20/min.

Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.

Temperature 38.3 °C (101 °F) Heart rate 152/min.

For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.

Each finding may support more than 1 disease process.

Choice A rationale:

Evaluating the client for signs of infection is an important nursing action in post-procedure care, but it is not the priority immediately following an amniotomy. The primary concern after an amniotomy is fetal well-being, so monitoring the fetal heart rate is the priority.

Choice B rationale:

Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. Amniotomy involves breaking the amniotic sac, which can potentially lead to changes in the fetal heart rate. Monitoring the fetal heart rate helps assess the baby's well-being and detects any signs of fetal distress.

Choice C rationale:

Observing the color and consistency of amniotic fluid is important for assessing the fluid for signs of meconium staining or infection, but it is not the immediate priority after an amniotomy. Checking the fetal heart rate takes precedence.

Choice D rationale:

Taking the client's temperature is an important part of assessing for infection or fever, but it is not the immediate priority following an amniotomy. Fetal well-being and monitoring are the primary concerns in the immediate post-amniotomy period.

Choice A rationale:

Documenting the medication error in the provider's progress notes is not the appropriate location for documenting a medication error. Progress notes are typically used to record the client's clinical progress and assessments, not incidents of medication errors.

Choice B rationale:

The controlled substance inventory record is used to track the dispensing and administration of controlled substances in a healthcare facility. Documenting a medication error in this record is not appropriate, as it is not the purpose of this document.

Choice C rationale:

Documenting the medication error in an incident report is the correct action. Incident reports are used to document and track adverse events or errors that occur in healthcare settings. This allows for proper investigation, analysis, and the implementation of preventive measures to avoid similar errors in the future.

Choice D rationale:

The nursing care plan is a document that outlines the client's nursing care needs, goals, and interventions. While it may include information about medication administration, it is not the appropriate place to document a medication error. An incident report is specifically designed for this purpose and ensures that the error is appropriately addressed and investigated.