QUESTION: "For a primigravid client with the fetal presenting part at -1 station, which of the following would be the nurse's priority immediately after an amniotomy?"
CHOICES
( X ) a.) Positioning the client on her left side.
( X ) b.) Preparing the client for a cesarean delivery.
( X ) c.) Assessing the client's blood pressure.
( O ) d.) Checking for prolapsed umbilical cord.
RATIONALE: Immediately after an amniotomy (artificial rupture of the membranes), the nurse should inspect the perineal area to detect cord prolapse. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. The color, amount, and odor of the amniotic fluid should be noted. Fetal heart rate should be monitored. Although the optimal position for the client is on the left side, this is not a priority at this time. The client is not having a precipitous delivery with the fetal skull at -1 station. Therefore, preparing the client for a cesarean delivery is unnecessary. Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
