49. A client, who is gravida 3, para 1 at 37 weeks' gestation, is dilated to 5 cm, 100% effaced, and at a –2 station. A physician performs an amniotomy to augment the progress of labor. After an amniotomy, which should a nurse assess first?
49. A client, who is gravida 3, para 1 at 37 weeks' gestation, is dilated to 5 cm, 100% effaced, and at a –2 station. A physician performs an amniotomy to augment the progress of labor. After an amniotomy, which should a nurse assess first?
. Degree of cervical dilation.
. Fetal heart tones.
. Client's vital signs.
. Client's level of discomfort.
Test-Taking Tip
When prioritizing nursing actions, the first priority should be to assess the fetal heart rate because it is directly affected by rupturing the amniotic sac. Note that three options relate to the woman, and one to the fetus. Select the option that is different.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Diagnostic Tests
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Answer 1 is incorrect because the physician usually examines the cervix directly before the amniotomy. The nurse does not need to reevaluate the cervix. Answer 2 is correct because, with amniotomy, there is a chance of prolapsed umbilical cord, and that results in fetal bradycardia. Assessing the fetal heart tones is the nurse's most important action. Answer 3 is incorrect because the maternal vital signs are not affected by the amniotomy, and do not need to be evaluated directly after amniotomy. Answer 4 is incorrect because the client's level of discomfort may increase after amniotomy, but pain is not the most important evaluation.