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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A: Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
Choice B: Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.

Choice C: Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
Choice D: Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.

A. Posterior neck flexion B. Increased abdominal muscle tone C. Gradual lordosis D. Decreased mobility of pelvic joints

Correct Answer is C

Explanation

Choice A: Posterior neck flexion is not an expected change during pregnancy.

Choice B: Increased abdominal muscle tone is not an expected change during pregnancy. In fact, the abdominal muscles tend to stretch and may become less toned as the uterus expands.

Choice C: During pregnancy, the woman's center of gravity shifts due to the growing uterus, leading to an increased arch in the lower back known as lordosis. This change helps to maintain balance and reduce the strain on the back. The other options are not expected physiologic changes during pregnancy.

Choice D: Decreased mobility of pelvic joints is not an expected change during pregnancy. Some joint laxity may occur due to hormonal changes, but decreased mobility is not typical.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is a primigravida, at term, and having contractions. The client states that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as the most reliable sign of true labor?

Correct Answer is B

Explanation

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?

Correct Answer is C

Explanation

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