A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.

Choice A Reason:

"I will get injections of the medication once daily until my labor stops." Terbutaline is typically administered as a subcutaneous injection or orally, but the frequency can vary. It is often given as needed or on a scheduled basis, depending on the healthcare provider's instructions. However, "once daily until labor stops" is not a typical approach.

Choice B Reason:

"My blood sugar may be low while I'm on this medication." While terbutaline can affect glucose metabolism, it is more commonly associated with hyperglycemia (high blood sugar) rather than hypoglycemia (low blood sugar).

Choice C Reason:

"I will have blood tests because my potassium might decrease." Terbutaline, a beta-2 adrenergic agonist, can potentially lead to hypokalemia (a decrease in potassium levels). Monitoring potassium levels through blood tests is important during terbutaline therapy.

Choice D Reason:

"My blood pressure may increase while I'm on this medication." Terbutaline is known to cause cardiovascular side effects, but an increase in blood pressure is not a common effect. It is more associated with tachycardia (increased heart rate) and potential hypotension. Monitoring blood pressure is still important, but an increase is less likely compared to other cardiovascular effects.