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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 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.

Correct Answer is B

Explanation

Choice A rationale

Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so

frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.

Choice B rationale

Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation,

leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.

Choice C rationale

Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to

treat or prevent hypoxia, which is not a primary concern in this scenario.

Choice D rationale

Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial

action to take for preventing hypotension.

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