A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action immediately following this procedure?
Assess the client's temperature.
Assess the fetal heart rate and pattern.
Record color and consistency of fluid in the chart.
Evaluate the client for the presence of chills and increased uterine tenderness using palpation.
The Correct Answer is B
Choice A: Assessing the client's temperature is important, but it is not the priority immediately after an amniotomy. Fetal wellbeing takes precedence.
Choice B; After an amniotomy (artificial rupture of membranes), the priority nursing action is to assess the fetal heart rate and pattern. The procedure may cause changes in fetal heart rate and indicate fetal distress or cord compression, requiring immediate attention.
Choice C: Recording the color and consistency of fluid is relevant for documentation but does not address the immediate concern of fetal wellbeing.
Choice D: Evaluating the client for chills and uterine tenderness is not the priority after an amniotomy. Monitoring the fetal heart rate is crucial to detect any signs of distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.
Correct Answer is B
Explanation
Choice A: Leukorrhea, which refers to an increase in vaginal discharge, is a common discomfort during pregnancy and is generally not a cause for concern.
Choice B: Painful and tender areas on the leg may be a sign of deep vein thrombosis (DVT), a potentially dangerous condition. During pregnancy, there is an increased risk of developing blood clots, and DVT can be a serious complication that requires immediate medical attention.
Choice C: Nausea and vomiting are common in early pregnancy and are usually associated with morning sickness. While it can be uncomfortable, it is generally not considered a dangerous symptom unless it leads to severe dehydration.
Choice D: Urinary frequency is a common discomfort during pregnancy, especially in the first and third trimesters. Although it can be bothersome, it is not typically a sign of immediate danger.
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