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 D

Explanation

Leopold maneuvers are used to determine the fetal position and presentation by palpating the abdomen. ROA stands for Right Occiput Anterior, which means the baby's head is presenting and facing towards the mother's right side (Occiput) and positioned anteriorly (front of the pelvis).

This position is a common and favorable presentation for a vaginal delivery.

Choice A: Shoulder presentation is when the baby is presenting with the shoulder rather than the head. It is an abnormal presentation and requires a cesarean delivery.

Choice B: Mentum presentation is a type of face presentation, where the baby's chin (mentum) is presenting instead of the head. It is also an abnormal presentation and usually requires a cesarean delivery.

Choice C: Breech presentation is when the baby's buttocks or feet are presenting first instead of the head. It is another abnormal presentation that may require a cesarean delivery or careful vaginal delivery with a skilled healthcare provider.

A. "I will monitor my weight gain during the remaining months." B. "I will use only nonprescription medications while pregnant." C. "I will tell my doctor before using home remedies for nausea." D. will reduce my stress level."

Correct Answer is B

Explanation

A. "I will monitor my weight gain during the remaining months."

Correct: Monitoring weight gain during pregnancy is an appropriate action as it helps to ensure the baby's growth and overall health.
B. "I will use only nonprescription medications while pregnant."

Incorrect: This statement indicates a need for further teaching. Nonprescription medications may not be safe during pregnancy, as some overthecounter drugs can potentially harm the
fetus. It's essential for pregnant women to consult their healthcare provider before taking any medications.
C. "I will tell my doctor before using home remedies for nausea."

Correct: This statement shows the client's understanding that it's important to consult with their healthcare provider before using any home remedies during pregnancy, as some
remedies may not be safe for the developing fetus.

D. "I will reduce my stress level."

Correct: Managing stress during pregnancy is beneficial for both the mother and the baby. It indicates a good understanding of selfcare during pregnancy.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an ROA position. Which of the following fetal presentations should the nurse document in the client's medical record?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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