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 A
Explanation
A. "This medication promotes softening of the cervix."
A. Dinoprostone is a prostaglandin E2 analogue that is used to ripen the cervix by promoting softening and effacement. This is an important step in preparing the cervix for labor induction or augmentation.
B. Dinoprostone does not cause relaxation of the uterine muscles. Instead, it specifically works on the cervix to make it more favorable for labor.
C. Dinoprostone is not used to treat preeclampsi
A. It is primarily used for cervical ripening in the context of labor induction or augmentation.
D. Dinoprostone is not used to treat genital herpes simplex virus. It is specifically employed for its effects on cervical ripening and preparing the cervix for labor.
Correct Answer is B
Explanation
The correct answer is B. Uteroplacental insufficiency.
A. Umbilical cord compression is more commonly associated with variable decelerations, not late decelerations. Variable decelerations are characterized by abrupt decreases and increases in the fetal heart rate.
B. Late decelerations are indicative of uteroplacental insufficiency.
Uteroplacental insufficiency refers to a decrease in blood flow and oxygen supply from the mother to the fetus. Late decelerations occur after the peak of the contraction and may suggest inadequate oxygenation to the fetus.
C. Fetal head compression is associated with early decelerations, not late decelerations. Early decelerations typically coincide with the contractions and are considered a normal response to head compression during contractions.
D. Maternal bradycardia is not typically associated with late decelerations. Late decelerations are primarily related to issues with oxygenation and blood flow to the fetus.
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