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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.

Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.

Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.

Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.

A. This test assesses fetal lung maturity in the premature fetus. B. It provides an assessment of various signs of physical and physiological wellbeing in the fetus. C. This test identifies an Rh incompatibility between an Rhnegative mother and her unborn fetus. D. It is a maternal blood screening test to identify neural tube defects (also known as spinal defects) and Down syndrome in the fetus.

Correct Answer is D

Explanation

Choice A: Fetal lung maturity is not assessed through maternal serum alphafetoprotein testing. It is usually evaluated through tests such as amniocentesis or specialized ultrasound examinations closer to the third trimester.
Choice B: The maternal serum alphafetoprotein test specifically screens for certain birth defects and genetic conditions in the fetus, rather than general signs of physical and physiological
wellbeing.

Choice C: The maternal serum alphafetoprotein test is not used to identify Rh incompatibility. Rh incompatibility is determined through blood tests that assess the Rh factor of the mother's blood and the Rh status of the baby.
Choice D: The maternal serum alphafetoprotein test is a blood screening test that can identify neural tube defects (such as spina bifida) and chromosomal abnormalities (such as Down syndrome) in the fetus. The test measures the levels of alphafetoprotein in the mother's blood, and abnormal levels may indicate the need for further diagnostic testing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

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