A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.

The correct answer is A. Decreased platelet count.

A. Decreased platelet count: ITP is characterized by a decreased platelet count. It is an autoimmune disorder where the immune system attacks and destroys platelets, leading to a reduction in the number of circulating platelets.

B. Increased erythrocyte sedimentation rate (ESR): ITP is not typically associated with an increased ESR. ESR is a marker of inflammation, and ITP is primarily a disorder of platelet destruction rather than inflammation.

C. Decreased megakaryocytes: ITP is often associated with normal or increased numbers of megakaryocytes in the bone marrow. Megakaryocytes are the precursor cells for platelets, and their increased presence indicates that the bone marrow is trying to produce more platelets to compensate for the destruction occurring in the bloodstream.

D. Increased WBC: ITP primarily affects platelet counts and does not necessarily lead to an increased white blood cell (WBC) count. The primary concern in ITP is the risk of bleeding due to low platelet levels.