Health Promotion and Maintenance
78. A client, who is gravida 3, para 0 at 39 weeks' gestation, is admitted to a labor and delivery unit in active labor. The physician performs an amniotomy. Which assessment finding should a nurse anticipate after the amniotomy?
. Fetal heart tones 90 bpm.
. A moderate amount of straw-colored fluid.
. A small amount of greenish fluid.
. A small segment of the umbilical cord.
Test-Taking Tip
This question is asking which finding is normal after rupture of membranes. Think about the normal color and consistency of amniotic fluid.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Planning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Diagnostic Tests
Health Promotion and Maintenance
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Answer 1 is incorrect because fetal heart tones less than 110 bpm is bradycardia and not a normal finding after amniotomy. Answer 2 is correct because a moderate amount of straw-colored fluid is a normal color and an amount of amniotic fluid that is expected after the artificial rupture of membranes. Answer 3 is incorrect because a small amount of greenish fluid is meconium staining, not a normal result after amniotomy. Answer 4 is incorrect because a small segment of the umbilical cord would be a prolapsed cord, which is an obstetric emergency.