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 A

Explanation

A) Peanut butter:
Peanut butter is high in phenylalanine, the amino acid that individuals with phenylketonuria (PKU) are unable to metabolize properly. Therefore, individuals with PKU should avoid consuming foods high in phenylalanine, such as peanut butter.

B) Broccoli
C) Apple juice
D) Potatoes:
These foods are low in phenylalanine and do not need to be eliminated from the client's diet. In fact, they can provide essential nutrients during pregnancy. However, the client should be encouraged to consume foods that are low in phenylalanine to prevent complications associated with PKU.

A. Have the client ambulate. B. Apply warm, moist heat to the client's lower extremities. C. Place pillows under the client's knees when resting in bed. D. Massage the client's posterior lower legs.

Correct Answer is A

Explanation

A) Have the client ambulate:
Encouraging the client to ambulate is important for preventing thromboembolic complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Early ambulation promotes venous return, reduces stasis, and decreases the risk of blood clots forming in the lower extremities. However, the nurse should ensure the client's safety and provide assistance as needed.

B) Apply warm, moist heat to the client's lower extremities:
While warm, moist heat can provide comfort, it is not the priority intervention for a client with a history of thromboembolic disease. In fact, heat application could potentially increase blood flow to the lower extremities, which may exacerbate the risk of thrombosis in this client population.

C) Place pillows under the client's knees when resting in bed:
Placing pillows under the client's knees can help alleviate pressure on the lower back and enhance comfort, but it does not directly address the prevention of thromboembolic complications in a client with a history of thromboembolic disease.

D) Massage the client's posterior lower legs:
Massaging the client's posterior lower legs is contraindicated in individuals with a history of thromboembolic disease, as it can potentially dislodge blood clots and lead to embolism. This intervention could increase the risk of thromboembolic events rather than prevent them.

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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?

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