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Chapter 2: Problem 76

After the physician performs an amniotomy, the nurse's first action should be to assess the: A. Degree of cervical dilation B. Fetal heart tones C. Client's vital signs D. Client's level of discomfort

Short Answer

Expert verified
Answer: B. Assess the fetal heart tones

Step by step solution

01

Understand the amniotomy procedure

An amniotomy is a procedure in which the doctor artificially breaks the amniotic sac to induce or speed up labor. It is important to know and understand the procedure to determine the appropriate steps to take immediately following the amniotomy.
02

Review priorities after an amniotomy

Immediately after an amniotomy, the nurse should prioritize care to ensure the safety of both the client and the fetus. This involves monitoring the client's vital signs, assessing the cervix for dilation, and ensuring the fetus is in a stable condition with normal heart tones. A change in heart tones could signal distress or other complications for the fetus.
03

Evaluate Option A: Degree of cervical dilation

Assessing the degree of cervical dilation is important during labor. However, it is not the first priority immediately following an amniotomy. This option can be eliminated.
04

Evaluate Option B: Fetal heart tones

Monitoring the fetal heart tones is the most important step to take immediately following an amniotomy. The fetus may experience distress, and early detection can lead to rapid interventions to prevent any complications. This is the first action nurse should take and the correct answer to the exercise.
05

Evaluate Option C: Client's vital signs

Assessing the client's vital signs is important after an amniotomy, but it is not the first priority. The immediate concern should be the fetus's well-being, as changes in the fetal heart tones can indicate distress. This option can be eliminated.
06

Evaluate Option D: Client's level of discomfort

Assessing the client's level of discomfort is important but not the first priority immediately following an amniotomy. The immediate concern should be the fetus's well-being, as changes in the fetal heart tones can indicate distress. This option can be eliminated. The correct answer is: B. Fetal heart tones

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