A nurse is caring for a client who is about to undergo an amniotomy. What is the priority nursing action following this procedure?
Assess the fetal heart rate pattern.
Observe the color and consistency of fluid.
Assess the client’s temperature.
Evaluate the client for the presence of chills and increased uterine tenderness using palpation.
The Correct Answer is A
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ceftriaxone (Rocephin) is an antibiotic that is often used to treat bacterial infections, but it is not typically the first line of treatment for herpes.
Choice B rationale
Penicillin G intravenously is a type of antibiotic that is often used to treat bacterial infections. However, herpes is a viral infection, and antibiotics are not effective against viruses.
Choice C rationale
Acyclovir is an antiviral medication that is commonly used to treat herpes infections. It works by slowing the growth and spread of the herpes virus in the body. This would be the most appropriate treatment for a patient presenting with symptoms of a herpes outbreak.
Choice D rationale
Betamethasone is a type of corticosteroid that is often used to reduce inflammation. While it might help to reduce some of the inflammation and discomfort associated with herpes lesions, it would not address the underlying viral infection.
Correct Answer is C
Explanation
Choice A rationale
Placing a newborn under a radiant heat warmer after birth does not directly prevent basal metabolic rate reduction. The primary function of a radiant heat warmer is to maintain the newborn’s body temperature and prevent hypothermia.
Choice B rationale
While brown fat production is a mechanism used by newborns to generate heat, placing a newborn under a radiant heat warmer does not stimulate brown fat production.
Choice C rationale
The primary purpose of placing a newborn under a radiant heat warmer after birth is to maintain the newborn’s body temperature. Newborns can lose heat rapidly, as they have a
large surface area compared to their body weight. The radiant heat warmer provides a controlled environment that helps maintain the newborn’s body temperature.
Choice D rationale
Preventing hypothermia is a key reason for placing a newborn under a radiant heat warmer. However, the direct purpose of the warmer is to maintain the newborn’s body temperature.
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