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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Correct Answer is C
Explanation
A) Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B) Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C) Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacental
insufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D) Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.
Correct Answer is C
Explanation
The correct answer is: c. 42022
Choice A: 40122
Reason: This choice is incorrect because it indicates 4 pregnancies (correct), 0 term births (correct), 1 preterm birth (correct), 2 abortions (correct), but 2 living children (incorrect). The client has 2 living children, which is correct, but the term and preterm counts are not accurate.
Choice B: 20020
Reason: This choice is incorrect because it indicates 2 pregnancies (incorrect), 0 term births (correct), 0 preterm births (incorrect), 2 abortions (correct), and 0 living children (incorrect). The client has had 4 pregnancies, 1 preterm birth, and 2 living children.
Choice C: 42022
Reason: This choice is correct. It indicates 4 pregnancies (current pregnancy, elective abortion, twins, spontaneous abortion), 0 term births, 2 preterm births (twins at 36 weeks), 2 abortions (elective at 9 weeks, spontaneous at 15 weeks), and 2 living children (twins).
Choice D:
The GTPAL system is used to assess a client's obstetric history:
- G (Gravida): The total number of pregnancies, including the current one.
- T (Term births): The number of pregnancies carried to at least 37 weeks.
- P (Preterm births): The number of pregnancies delivered between 20 and 36 weeks, 6 days.
- A (Abortions): The number of pregnancies ending before 20 weeks (spontaneous or elective).
- L (Living children): The number of children currently alive.
For this client:
G (Gravida): 4 (one elective abortion, one twin pregnancy, one spontaneous abortion, and the current pregnancy).
- T (Term births): 0 (the twin pregnancy was delivered at 36 weeks, which is preterm).
- P (Preterm births): 1 (twins delivered at 36 weeks count as one preterm birth).
- A (Abortions): 2 (one elective abortion at 9 weeks, one spontaneous abortion at 15 weeks).
- L (Living children): 2 (the twins).
Thus, the GTPAL for this client is 4-0-1-2-2.
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