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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: An ultrasound can indeed determine the number of fetuses if a client is carrying multiples, but this is not the primary reason for performing an ultrasound before amniocentesis.
Choice B: An ultrasound is typically done before an amniocentesis to visualize the location of the placenta and fetus. This information is important to ensure that the amniocentesis needle is safely inserted away from the placenta and the fetus.
Choice C: The primary purpose of an amniocentesis is to obtain a sample of amniotic fluid to screen for genetic conditions, not specifically for spina bifida.
Choice D: Fetal age can be estimated through an ultrasound, but this is not the primary reason for performing an ultrasound before an amniocentesis. The main goal of the procedure is to obtain a sample of amniotic fluid for genetic testing.
Correct Answer is A
Explanation
A. A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B. Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C. Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D. Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.
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