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?

Assess the fetal heart rate.

Provide clean, dry underpads.

Assess the odor of the amniotic fluid.

Monitor the client's temperature.

Answer and Explanation

The Correct Answer is A

Choice A: After an amniotomy (artificial rupture of membranes), the priority action by the nurse is to assess the fetal heart rate. Amniotomy can lead to changes in fetal heart rate patterns, and the nurse needs to ensure that the baby's wellbeing is not compromised after the procedure.

Choice B: Providing clean, dry underpads is important for maintaining hygiene and cleanliness after the procedure but is not the priority action. The fetal heart rate assessment takes precedence.

Choice C: Assessing the odor of the amniotic fluid is essential to identify any signs of infection, but it is not the priority action immediately following the amniotomy. Fetal wellbeing is the priority.

Choice D: Monitoring the client's temperature is important for identifying any signs of infection, but it is not the priority action. Assessing the fetal heart rate is more critical at this time.

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Correct Answer is C

Explanation

A. "Increase your intake of ironrich foods and take a prenatal vitamin."
Important, but not directly related to reducing the risk of neural tube defects. Ironrich foods and prenatal vitamins are essential for overall maternal and fetal health, but they do not specifically target neural tube defect prevention.
B. "Avoid any alcohol consumption."
Important advice during pregnancy to prevent fetal alcohol spectrum disorders, but not directly related to reducing the risk of neural tube defects.
C. "Take a folic acid supplement for at least 3 months before you get pregnant."
Correct: Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects in newborns.
D. "Avoid all foods containing aspartame."Aspartame is an artificial sweetener that has been studied for safety in pregnancy, and there is currently no strong evidence linking it to neural tube defects. However, it's still a good idea
to limit the intake of artificial sweeteners during pregnancy and focus on a balanced diet.

A. "Assist the client in slowing her hyperventilation and breathe into a paper bag." B. "Administer oxygen via nasal cannula while encouraging her to pant." C. "Have the client tuck her chin to her chest." D. "Instruct the client to increase her respiratory rate to more than 42 breaths per minute."

Correct Answer is A

Explanation

Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.

Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.

Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.

Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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