A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?
Assess the fetal heart rate pattern.
Observe color and consistency of fluid.
Assess the client's temperature.
Evaluate client for the presence of chills and increased uterine tenderness using palpation.
The Correct Answer is A
A. Assess the fetal heart rate pattern: Following an amniotomy, the priority nursing action is to assess the fetal heart rate pattern. This procedure involves rupturing the amniotic sac, which can result in changes in fetal heart rate and may indicate fetal distress. Monitoring the fetal heart rate immediately after the procedure allows the nurse to detect any signs of fetal compromise and initiate prompt interventions if necessary.
B. Observe color and consistency of fluid: While assessing the color and consistency of the amniotic fluid is an essential nursing action after an amniotomy, it is not the priority. The priority is to ensure the well-being of the fetus by monitoring the fetal heart rate for any signs of distress.
C. Assess the client's temperature: While monitoring the client's temperature is important for detecting signs of infection following an amniotomy, it is not the priority immediately after the procedure. Assessing the fetal heart rate takes precedence to ensure the fetal well-being.
D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation: While assessing for signs of infection, such as chills and increased uterine tenderness, is important after an amniotomy, it is not the priority. Monitoring the fetal heart rate is the priority to detect any signs of fetal distress.
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Related Questions
Correct Answer is D
Explanation
A. Report of pain above the umbilicus: Pain above the umbilicus is not a definitive sign of labor. Pain during labor typically originates in the lower abdomen and back, as the uterus contracts to facilitate cervical dilation and effacement.
B. Amniotic fluid in the vaginal vault: While the rupture of membranes (amniotic fluid leaking) can be a sign of labor, its presence alone does not confirm active labor. Labor is typically confirmed by progressive cervical changes, such as dilation and effacement.
C. Brownish vaginal discharge: Brownish vaginal discharge could indicate the presence of old blood, which might be a sign of bloody show, but it alone does not confirm active labor. Labor is typically confirmed by progressive cervical changes, such as dilation and effacement.
D. Cervical dilation: Cervical dilation is one of the primary indicators of labor. In a primigravida at 42 weeks of gestation who believes she is in labor, cervical dilation would confirm the onset of labor.
Correct Answer is B
Explanation
A) Polyuria:
Polyuria (excessive urination) is not typically associated with severe preeclampsia. Instead, clients with severe preeclampsia often experience oliguria (decreased urine output) due to reduced kidney function.
B) Report of headache:
A headache is a common symptom of severe preeclampsia due to cerebral vasospasm and increased intracranial pressure. It is often described as persistent and severe.
C) Tachycardia:
Tachycardia is not a typical finding in severe preeclampsia. In fact, bradycardia or normal heart rate is more common due to increased peripheral vascular resistance.
D) Absence of clonus:
Clonus, characterized by rhythmic contractions and relaxations of a muscle, particularly when the foot is quickly dorsiflexed, is a characteristic finding in preeclampsia. Absence of clonus is not expected in a client with severe preeclampsia.
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