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: Urinary frequency is a common symptom during pregnancy, especially in the first trimester and near the end of the pregnancy. During the first trimester, it is mainly due to
hormonal changes and increased blood flow to the pelvic area. In the later stages, it is caused by the growing uterus putting pressure on the bladder.
Choice B: Dismissing the client's concern as a minor inconvenience is not appropriate and may disregard the client's experience.
Choice C: While it is true that each individual client's experience may vary, it is important to provide the client with information regarding common patterns.
Choice D: Providing accurate information about the duration of urinary frequency is important. While it may last until the 12th week for many women, it does not continue throughout the entire pregnancy for most individuals, regardless of bladder tone.
Correct Answer is B
Explanation
Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.
Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.
Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.
Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.
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