Which assessment immediately after an amniotomy needs to be conducted first?
Vaginal discharge
Bladder distention
Maternal Blood Pressure
Fetal heart rate pattern
The Correct Answer is D
A. Vaginal discharge should be assessed to monitor the amount, color, and odor of the amniotic fluid, which can provide information about membrane rupture and possible infection. However, this assessment is secondary to fetal well-being. While it is important to note whether the fluid is clear, meconium-stained, or foul-smelling, it does not provide immediate information about fetal compromise, making it less urgent than FHR assessment.
B. Bladder distention can interfere with labor progression by preventing fetal descent and may require catheterization. Although important during labor management, bladder assessment is not time-critical immediately after amniotomy, and addressing it does not take priority over detecting potential fetal compromise.
C. Maternal blood pressure is routinely monitored to assess maternal cardiovascular status and detect hypertensive disorders such as preeclampsia. While maternal stability is important, unless the mother has known hypertension or symptoms of hypotension, it is not the most urgent assessment immediately after membrane rupture.
D. Fetal heart rate pattern is the priority assessment immediately after amniotomy. Artificial rupture of membranes can increase the risk of umbilical cord prolapse, cord compression, or sudden changes in amniotic fluid volume, all of which can compromise fetal oxygenation. Continuous FHR monitoring allows the nurse to detect variable decelerations, bradycardia, or other signs of fetal distress immediately, enabling prompt interventions such as maternal repositioning, oxygen administration, or notifying the healthcare provider. Monitoring FHR first ensures immediate fetal safety, which is the most critical concern following an amniotomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Iron deficiency anemia results from insufficient iron intake, increased maternal iron requirements, or blood loss, not from folic acid deficiency. Although folic acid and iron are both important for maternal and fetal health, the specific deficiency effects differ. Iron is primarily critical for hemoglobin synthesis, whereas folic acid supports DNA synthesis and cell division.
B. Bone development depends mainly on adequate calcium, phosphorus, and vitamin D. A folic acid deficiency does not directly affect skeletal formation in the fetus, as its primary role is in nucleic acid metabolism and cellular replication.
C. While severe folic acid deficiency may indirectly contribute to growth issues, it is not the main or hallmark consequence. Fetal growth restriction is more closely associated with placental insufficiency, maternal malnutrition, or other systemic conditions rather than isolated folic acid deficiency.
D. Folic acid deficiency is strongly linked to neural tube defects (NTDs) such as spina bifida and anencephaly. The neural tube closes within the first 3–4 weeks of gestation, often before pregnancy is confirmed, making preconception and early pregnancy supplementation critical. Recommended daily intake for women of childbearing age is 400–800 mcg, which significantly reduces the risk of NTDs. Folic acid’s role in DNA synthesis, cell division, and tissue growth is essential for proper neural tube development.
Correct Answer is D
Explanation
A. Placing the client in a knee-chest position is not necessary for routine assessment of contractions. This position may be used for specific interventions, such as relieving cord compression, but it does not aid in safe palpation of contractions.
B. Pushing down forcefully before each contraction is unsafe. Forceful palpation can increase discomfort, alter contraction patterns, or compromise fetal oxygenation, especially if uterine tone is high or the fetus is compromised.
C. Avoiding palpation entirely would limit the nurse’s ability to assess contraction frequency, duration, and intensity, which are essential parameters for evaluating labor progress and fetal well-being. Complete avoidance is not recommended unless contraindicated for specific reasons.
D. Palpating gently between contractions to assess uterine tone is the safest and most effective method. It allows the nurse to evaluate baseline uterine tone, contraction frequency, and strength without interfering with fetal oxygenation or increasing maternal discomfort. Gentle palpation helps detect hypertonicity or tetanic contractions, which can lead to fetal distress or uterine rupture if unrecognized.
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.