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 B
Explanation
Choice A rationale
A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other
conditions can also result in elevated hCG levels.
Choice B rationale
Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be
caused by other factors such as stress or hormonal imbalances.
Choice C rationale
Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of
pregnancy.
Choice D rationale
Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather
a physical change that occurs during pregnancy. .
Correct Answer is C
Explanation
Choice A rationale
Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.
Choice B rationale
Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.
Choice C rationale
Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.
Choice D rationale
Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.