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 B
Explanation
Choice A rationale
Inserting an indwelling urinary catheter is not the priority nursing action. While it may be necessary later, especially if the client goes to surgery, it is not the immediate concern.
Choice B rationale
Initiating IV access is the correct action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.
Choice C rationale
Witnessing the signature for informed consent for surgery is not the priority nursing action. While consent will be necessary if the client needs a cesarean section, the immediate concern is stabilizing the client.
Choice D rationale
Preparing the abdominal and perineal areas is not the priority nursing action. This would be done as part of surgical preparation if a cesarean section is needed, but it is not the immediate concern.
Correct Answer is D
Explanation
Choice A rationale
Flexing the knee while resting does not typically alleviate the symptoms of a possible DVT15161718.
Choice B rationale
Applying cold compresses is not typically recommended for the symptoms of a possible DVT15161718.
Choice C rationale
Massaging the area is not recommended, especially if the patient is showing signs of a possible DVT, as it could dislodge a clot.
Choice D rationale
Elevating the leg can help reduce swelling and improve blood flow, which can help alleviate pain associated with a possible DVT15161718.
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