A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy?

Fetal position

Fetal lie

Fetal attitude

fetal engagement

Answer and Explanation

The Correct Answer is D

The correct answer is D. Fetal engagement

A. Fetal position, fetal lie, and fetal attitude are important aspects of the fetal presentation but are not specific considerations when performing an amniotomy.

B. Fetal lie is the relationship between the long axis of the fetus and the long axis of the mother. It is not directly relevant to the consideration of amniotomy.

C. Fetal attitude refers to the relationship of the fetal body parts to each other. It is not a specific consideration for amniotomy.

D. Fetal engagement is the correct consideration prior to amniotomy.

Fetal engagement refers to the descent of the fetal presenting part into the pelvis. Before performing an amniotomy, it is important to confirm that the fetal head is engaged in the pelvis, ensuring a lower risk of cord prolapse.

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Correct Answer is D

Explanation

A. The cervix being effaced is not represented by the -1 notation in a vaginal examination. Effacement is usually expressed as a percentage.

B. The -1 notation does not represent cervical dilation. Dilation is measured in centimeters.

C. The presenting part being 1 cm below the ischial spines is not correct. In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.

D. The presenting part is 1 cm above the ischial spines is the correct interpretation.

In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.

A. Provide clean, dry underpads. B. Monitor the client's temperature. C. Assess the fetal heart rate. D. Assess the odor of the amnio?s fluid

Correct Answer is C

Explanation

The correct answer is C. Assess the fetal heart rate.

A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.

B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.

C. Assessing the fetal heart rate is the priority action.

Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.

D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.

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A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -1. Which of the following interpretations of this finding should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Correct Answer is C

Explanation

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