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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["732"]
Explanation
To calculate the total intake, we need to convert all measurements to the same unit, in this case, milliliters (mL).
1 ounce (oz) is approximately equal to 29.5735 mL.
Also, it’s important to note that when ice chips melt, they become about half their volume in water. So, 100 mL of ice chips would become about 50 mL of wate
Let’s calculate:
Juice: 4 oz * 29.5735 = 118.294 mL
Tea: 6 oz * 29.5735 = 177.441 mL
Ice chips: 100 mL * 0.5 = 50 mL
IV bolus: 150 mL
Broth: 8 oz * 29.5735 = 236.588 mL
Adding all these together:
118.294 mL (juice) + 177.441 mL (tea) + 50 mL (ice chips) + 150 mL (IV bolus) + 236.588 mL (broth) = 732.323 mL
So, the nurse should record 732 mL of intake on the client’s record (rounded to the nearest whole number).
Correct Answer is C
Explanation
A) Goodell's sign: Goodell's sign refers to cervical softening, which occurs in early pregnancy due to increased vascularity and edema. It is not specific to the presence of blood in the peritoneum and is not typically associated with a ruptured ectopic pregnancy.
B) Chvostek's sign: Chvostek's sign is a clinical sign of hypocalcemia and is elicited by tapping on the facial nerve, leading to facial muscle twitching. It is not related to the presence of blood in the peritoneum or ectopic pregnancy.
C) Cullen's sign: Cullen's sign is the presence of ecchymosis around the umbilicus, indicating intra-abdominal bleeding. It is a sign of retroperitoneal or intra-abdominal hemorrhage, which can occur in a ruptured ectopic pregnancy when blood leaks into the peritoneum. Cullen's sign is indicative of blood in the peritoneum and is associated with ectopic pregnancy rupture.
D) Chadwick's sign: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, which occurs in early pregnancy. It is not specific to the presence of blood in the peritoneum and is not typically associated with a ruptured ectopic pregnancy.
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