A DDA nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
O2 saturation
Temperature
Blood pressure
Urinary output
The Correct Answer is B
Choice A Reason:
Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence
Choice B Reason:
Temperature: Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is 38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes. The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.
Choice C Reason:
Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.
Choice D Reason:
Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
A. Maintain the client NPO throughout the procedure: It is not necessary to maintain the client NPO (nothing by mouth) for a nonstress test. The test primarily involves monitoring fetal heart rate in response to the baby's movements and does not require fasting.
B. Place the client in a supine position: Placing the client in a left lateral position is often preferred for NST to optimize uterine blood flow and fetal oxygenation. The supine position can compromise blood flow to the uterus and is generally avoided, especially in later pregnancy.
C. Instruct the client to massage the abdomen to stimulate fetal movement: While the goal of the NST is to monitor fetal movements, instructing the client to actively stimulate fetal movement through abdominal massage is not a standard part of the procedure. Fetal movements should occur naturally.
D. Instruct the client to press the provided button each time fetal movement is detected: This is the correct action. During a nonstress test, the client is typically provided with a button to press whenever she feels fetal movement. This helps correlate fetal movements with changes in the fetal heart rate on the monitor, providing valuable information about the baby's well-being.
Correct Answer is A
Explanation
The correct answer is A. Contractions lasting longer than 90 seconds.
A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.
B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.
C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.
D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.
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