A nurse is caring for a client who is about to undergo an amniotomy. What is the priority nursing action following this procedure?
Assess the fetal heart rate pattern.
Observe the color and consistency of fluid.
Assess the client’s temperature.
Evaluate the client for the presence of chills and increased uterine tenderness using palpation.
The Correct Answer is A
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1 is to determine the amount of heparin to administer. The client is receiving 3,800 units of heparin, and the available heparin is 5,000 units/mL.
Step 2 is to set up the calculation: (3,800 units ÷ 5,000 units/mL) = x mL.
Step 3 is to perform the calculation: x = 0.76 mL. Therefore, the nurse should administer 0.8 mL of heparin, rounded to the nearest tenth.
Correct Answer is B
Explanation
Choice A rationale
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
Choice B rationale
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
Choice C rationale
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
Choice D rationale
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.
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.