A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

A. Increase in blood pressure: Methylergonovine can cause an increase in blood pressure, but this is a side effect of the medication, not an indication of its effectiveness.

B. Report of absent breast pain: Methylergonovine is not typically used to treat breast pain, so this would not be an indication of its effectiveness.

C. Fundus firm to palpation: This is the correct answer. Methylergonovine is a medication used to prevent or control postpartum hemorrhage by causing the uterus to contract. A firm fundus upon palpation indicates that the uterus is contracting effectively, which is the desired effect of the medication.

D. Increase in lochia: An increase in lochia (vaginal discharge after childbirth) is not an indication of the effectiveness of Methylergonovine. In fact, heavy lochia can be a sign of postpartum hemorrhage, which the medication is intended to prevent. Therefore, an increase in lochia would not indicate that the medication is working effectively.

A. Evaluate client for the presence of chills and increased uterine tenderness using palpation: While this is an important assessment, it is not the priority following an amniotomy. The priority is to assess the well-being of the fetus, which is done by assessing the fetal heart rate pattern.

B. Observe color and consistency of fluid: Observing the color and consistency of the amniotic fluid is important to identify potential complications such as meconium-stained amniotic fluid. However, the priority is to assess the fetal heart rate pattern to ensure fetal well-being.

C. Assess the client’s temperature: While monitoring the client’s temperature is important to identify potential infection, the priority following an amniotomy is to assess the fetal heart rate pattern.

D. Assess the fetal heart rate pattern: This is the correct choice. The priority nursing action following an amniotomy is to assess the fetal heart rate pattern. This is done to ensure fetal well-being, as complications such as cord prolapse can occur following an amniotomy, which would be indicated by changes in the fetal heart rate pattern. If cord prolapse is suspected, emergency measures would need to be taken. Therefore, assessing the fetal heart rate pattern is the priority nursing action.