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 A
Explanation
Choice A rationale
Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.
Choice B rationale
Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.
Choice C rationale
Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.
Choice D rationale
Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.
Correct Answer is D
Explanation
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.