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.
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Related Questions
Correct Answer is C
Explanation
A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.
B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.
C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.
D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.
Correct Answer is B
Explanation
A. Incorrect. Weightbearing exercises should be avoided or limited during pregnancy, as they can increase the risk of injury, joint pain, and fatigue.
B. Correct. Moderate exercise can improve circulation, reduce swelling, and prevent varicose veins during pregnancy.
C. Incorrect. Resting for 30 minutes before each new exercise is not necessary and may reduce the benefits of physical activity.
D. Incorrect. Stretching exercises can help prevent muscle cramps, improve flexibility, and reduce back pain during pregnancy.
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