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A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.
Which of the following statements should the charge nurse include during the discussion?

A.

Check the client's temperature frequently following the procedure.

B.

Insert misoprostol rectally every 2 hours following the procedure.

C.

Obtain a biophysical profile during the procedure.

D.

Perform effleurage to the client's abdomen during the procedure.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early

detection and management of any potential infections.

 

Choice B rationale

Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage,

not for routine use post-amniotomy.

 

Choice C rationale

Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.

 

Choice D rationale

Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.

Choice B rationale

Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.

Choice C rationale

A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.

Choice D rationale

Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Delay in initiating breastfeeding can occur after a cesarean birth due to the effects of anesthesia, postoperative recovery, and the need for medical monitoring, which can delay the mother’s ability to start breastfeeding.

Choice B rationale

Routine use of intubation equipment is not standard practice during a cesarean birth. Intubation is typically reserved for patients who require general anesthesia or have complications that necessitate airway management.

Choice C rationale

The need for an indwelling urinary catheter is common during a cesarean birth. It helps to keep the bladder empty and out of the way during the procedure and is usually placed after anesthesia and removed shortly after the surgery.

Choice D rationale

Management of postpartum pain is an important topic to discuss with clients undergoing cesarean birth. Postoperative pain management may include medications and non-pharmacological methods to ensure comfort and aid in recovery.

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