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?
Assess the fetal heart rate.
Provide clean, dry underpads.
Assess the odor of the amniotic fluid.
Monitor the client's temperature.
The Correct Answer is A
Choice A: After an amniotomy (artificial rupture of membranes), the priority action by the nurse is to assess the fetal heart rate. Amniotomy can lead to changes in fetal heart rate patterns, and the nurse needs to ensure that the baby's wellbeing is not compromised after the procedure.
Choice B: Providing clean, dry underpads is important for maintaining hygiene and cleanliness after the procedure but is not the priority action. The fetal heart rate assessment takes precedence.
Choice C: Assessing the odor of the amniotic fluid is essential to identify any signs of infection, but it is not the priority action immediately following the amniotomy. Fetal wellbeing is the priority.
Choice D: Monitoring the client's temperature is important for identifying any signs of infection, but it is not the priority action. Assessing the fetal heart rate is more critical at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which play a crucial role during childbirth. Strengthening these muscles can aid in better control during labor and delivery, facilitating stretching and reducing the risk of injury.
Choice B: Kegel exercises do not have a direct impact on preventing constipation during pregnancy. However, they may help improve bowel control and prevent fecal incontinence.
Choice C: While Kegel exercises can improve posture and core strength, their primary benefit lies in strengthening the pelvic muscles, not directly reducing backaches throughout pregnancy.
Choice D: Kegel exercises are not intended to prevent stretch marks on the abdomen. Stretch marks are caused by the stretching of the skin during pregnancy and are not related to pelvic muscle exercises.
Correct Answer is C
Explanation
The correct answer is: c. The cervix is 1 cm dilated.
Choice A reason:
The presenting part is 1 cm above the ischial spines. This statement would be documented as -1 station. Fetal station is measured in centimeters relative to the ischial spines, with negative numbers indicating the presenting part is above the spines.
Choice B reason:
The cervix is effaced 1 cm. Effacement is measured in percentages, not centimeters. It refers to the thinning of the cervix, which progresses from 0% (not effaced) to 100% (fully effaced).
Choice C reason:
In obstetrics, a sterile vaginal exam (SVE) is recorded using a standard three-part shorthand: Dilation / Effacement / Station.Dilation: This is always the first number in the sequence. It measures the opening of the cervix from 0 to 10 centimeters. Therefore, if the finding begins with the number 1, it indicates the cervix has opened to a diameter of 1 cm.
Choice D reason:
The presenting part is 1 cm below the ischial spines. This would be documented as +1 station. Positive numbers indicate the presenting part is below the ischial spines, moving towards delivery.
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