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 B
Explanation
A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.
B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.
C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.
D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.
Correct Answer is D
Explanation
A) Accelerations:
Accelerations in the fetal heart rate are generally considered a reassuring sign and indicate fetal well-being. They reflect a responsive and healthy fetus.
B) Late decelerations:
Late decelerations are associated with uteroplacental insufficiency and indicate that the fetus may not be getting enough oxygen. While this is a concerning pattern, it is not specifically indicative of an umbilical cord problem.
C) Early decelerations:
Early decelerations are typically caused by fetal head compression during contractions and are generally considered benign. They usually do not indicate a problem with the umbilical cord.
D) Variable decelerations:
Variable decelerations are often caused by umbilical cord compression. They are characterized by abrupt decreases in fetal heart rate that vary in duration, intensity, and timing relative to uterine contractions. This pattern is indicative of issues with the umbilical cord, such as cord prolapse or nuchal cord (cord wrapped around the fetus's neck). Therefore, variable decelerations are the pattern most suggestive of a problem with the umbilical cord.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.