A nurse is caring for a client who is about to undergo an amniotomy. What is the priority nursing action following this procedure?

Choice A rationale
Excessive uterine enlargement is a common finding in a client with a hydatidiform mole. This is due to the overgrowth of trophoblastic tissue, which forms the placenta.
Choice B rationale
Profuse, clear vaginal discharge is not typically associated with a hydatidiform mole. The most common symptom is vaginal bleeding, which can be dark brown or bright red, and sometimes is described as looking like prune juice.
Choice C rationale
An irregular fetal heart rate is not a typical finding in a client with a hydatidiform mole, as this condition often results in a nonviable pregnancy.
Choice D rationale
A rapid decline in human chorionic gonadotropin (hCG) levels is not expected in a client with a hydatidiform mole. In fact, hCG levels are usually abnormally high in these cases.

Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on

the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.