A nurse is caring for a client during an amniotomy by the Certified Nurse Midwife.
What is the nurse's priority immediately after the amniotomy procedure?
Monitor and assess fetal heart rate.
Assist client to the bathroom.
Perform pericare.
Document the color, odor, and consistency of the fluid.
The Correct Answer is A
Choice A rationale
Monitoring and assessing fetal heart rate immediately after an amniotomy is crucial to detect any signs of fetal distress, such as cord prolapse or changes in fetal heart rate patterns. This intervention helps ensure the baby's well-being following the procedure.
Choice B rationale
Assisting the client to the bathroom is not the priority immediately after an amniotomy. The focus should be on monitoring the fetal heart rate and maternal condition first.
Choice C rationale
Performing pericare is important for maternal comfort and hygiene but should not take precedence over assessing fetal well-being immediately after an amniotomy.
Choice D rationale
Documenting the color, odor, and consistency of the amniotic fluid is necessary for record-keeping and assessing for signs of infection or meconium. However, it should follow the immediate assessment of fetal heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Monitoring and assessing fetal heart rate immediately after an amniotomy is crucial to detect any signs of fetal distress, such as cord prolapse or changes in fetal heart rate patterns. This intervention helps ensure the baby's well-being following the procedure.
Choice B rationale
Assisting the client to the bathroom is not the priority immediately after an amniotomy. The focus should be on monitoring the fetal heart rate and maternal condition first.
Choice C rationale
Performing pericare is important for maternal comfort and hygiene but should not take precedence over assessing fetal well-being immediately after an amniotomy.
Choice D rationale
Documenting the color, odor, and consistency of the amniotic fluid is necessary for record-keeping and assessing for signs of infection or meconium. However, it should follow the immediate assessment of fetal heart rate.
Correct Answer is C
Explanation
Choice A rationale
Category 1 fetal heart rate tracings are considered normal and reassuring, showing a baseline rate of 110-160 bpm, moderate variability, and accelerations with no late or variable decelerations.
Choice B rationale
Category 2 fetal heart rate tracings are indeterminate and may show minimal or marked variability, but they do not have absent variability with bradycardia.
Choice C rationale
Category 3 fetal heart rate tracings are abnormal and require immediate intervention. They include absent variability with recurrent late decelerations, recurrent variable decelerations, bradycardia, or a sinusoidal pattern.
Choice D rationale
A reactive tracing shows accelerations of the fetal heart rate with fetal movement, indicating well-being. This scenario does not fit the description of a reactive tracing.
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