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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

The priority action by the nurse following an amniotomy is to assess the fetal heart rate. This is because changes in the fetal heart rate can indicate fetal distress, which could be caused by cord compression or other complications related to the amniotomy.
Choice B rationale
While assessing the odor of the amniotic fluid is important to identify possible infections, it is not the priority action following an amniotomy.
Choice C rationale
Providing clean, dry underpads is part of standard care following an amniotomy, but it is not the priority action.
Choice D rationale
Monitoring the client’s temperature is important to identify possible infection, but it is not the priority action immediately following an amniotomy.

A. Drink 48 to 64 ounces of water daily. B. Consume 40 to 90 g of protein daily. C. Limit intake of whole grains, raw fruits, and vegetables. D. Avoid salting of foods during cooking

Correct Answer is A

Explanation

The correct answer is choice A. Drink 48 to 64 ounces of water daily.

Choice A rationale:

Drinking 48 to 64 ounces of water daily is recommended to help maintain hydration and support overall health during pregnancy, especially for those with mild preeclampsia.

Choice B rationale:

While protein intake is important, the recommended amount for pregnant women is generally higher than 40 to 90 grams per day. The exact amount can vary based on individual needs, but typically, pregnant women are advised to consume around 71 grams of protein daily.

Choice C rationale:

Limiting intake of whole grains, raw fruits, and vegetables is not recommended. These foods are rich in essential nutrients and fiber, which are beneficial for both the mother and the baby.

Choice D rationale:

Avoiding salting of foods during cooking can help manage blood pressure, but it is not the primary focus of dietary recommendations for preeclampsia. Reducing overall sodium intake is more important.

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A nurse is caring for a client who is about to undergo an amniotomy. What is the priority nursing action following this procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Correct Answer is A

Explanation

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

Correct Answer is A

Explanation

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