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.

Answer and Explanation

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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Correct Answer is B

Explanation

A) Fundus palpable at the umbilicus:
At 12 hours postpartum, it is normal for the fundus to be at the level of the umbilicus. This finding is expected as the uterus begins its process of involution.

B) Heart rate 110/min:
A heart rate of 110/min is indicative of tachycardia, which can be a sign of postpartum complications such as hemorrhage, infection, or dehydration. Tachycardia is concerning because it may indicate that the body is compensating for a significant loss of blood or other underlying issues.

C) Urine output of 3,000 mL in 12 hr:
Increased urine output is common in the immediate postpartum period as the body eliminates excess fluid retained during pregnancy. This is not indicative of a complication and is generally considered a normal finding.

D) Orthostatic hypotension:
Orthostatic hypotension can occur postpartum due to the body's adjustments after delivery and fluid shifts. While it needs to be monitored, it is not as immediate a concern as tachycardia, which could indicate more serious complications.

A. Contractions are strong in intensity B. Client reports feeling contractions in lower back C. Contractions occurring every 3 to 5 min D. Contractions lasting longer than 90 seconds

Correct Answer is D

Explanation

A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.

B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.

C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.

D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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