A client is to have an amniotomy to induce labor.The nurse recognizes that the priority intervention after the amniotomy is to:
A)Apply clean linens under the woman
B)Take the client's vital signs
C)Perform a vaginal examination
D)Assess the fetal heart rate (FHR)

Question

Quizplus · Accepted Answer

The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse.Providing comfort measures for the client is important,but it is not the priority immediately after an amniotomy.The woman's temperature should be checked every 2 hours after rupture of membranes,but this is not the priority at this time.The woman would have had a vaginal examination during the procedure.Unless cord prolapse is suspected,a vaginal examination is not warranted.Additionally,FHR assessment provides clinical cues to a prolapsed cord.

A Client Is to Have an Amniotomy to Induce Labor