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?
Check the client's temperature frequently following the procedure.
Insert misoprostol rectally every 2 hours following the procedure.
Obtain a biophysical profile during the procedure.
Perform effleurage to the client's abdomen during the procedure.
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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Correct Answer is D
Explanation
Choice A rationale
Repeating the CST isn't necessary with a negative result, which indicates no significant uterine contractions affecting the fetus.
Choice B rationale
Administering an IV fluid bolus is not warranted by a negative CST result.
Choice C rationale
Preparing for a cesarean birth isn't necessary since a negative CST indicates no immediate fetal distress.
Choice D rationale
A negative CST indicates that there are no late decelerations, so the nurse should allow the labor to progress naturally.
Correct Answer is D
Explanation
Choice A rationale
Taking iron supplements with milk is not advised because calcium in milk can interfere with the absorption of iron, reducing its effectiveness.
Choice B rationale
Doubling the dose of iron supplements if a dose is missed is not recommended because it can cause gastrointestinal issues and toxicity. It's better to just continue with the regular
dosing schedule.
Choice C rationale
Consuming 29 grams of fiber daily is a good practice for overall health, but it does not directly aid in iron absorption. Fiber can actually bind to iron and decrease its absorption in the
intestines.
Choice D rationale
Vitamin C enhances the absorption of non-heme iron (found in supplements) by converting it into a more absorbable form. Taking vitamin C with iron supplements increases their
effectiveness, making this statement correct.