Question

"An amniotomy is performed to stimulate labor in a client who is at 42 weeks' gestation. Place the nursing care in order of priority.

A. Check the fetal heart rate tracings.
B. Evaluate the client for signs of an infection.
C. Assess the characteristics of the amniotic fluid.
D. Observe the perineum for umbilical cord prolapse"

Answer 1

The nursing care in order of priority for a client undergoing an amniotomy to stimulate labor at 42 weeks' gestation is to first check the fetal heart rate tracings. Next, evaluate the client for signs of infection. Assessing the characteristics of the amniotic fluid and observing the perineum for umbilical cord prolapse are of lower priority.

Step-by-step explanation:

The nursing care in order of priority for a client who undergoes an amniotomy to stimulate labor at 42 weeks' gestation should be:

1. Check the fetal heart rate tracings: This is the highest priority as it ensures the well-being of the fetus and helps monitor for any distress.
2. Evaluate the client for signs of an infection: This is the next priority as amniotomy increases the risk of infection, so it's crucial to assess for any signs or symptoms.
3. Assess the characteristics of the amniotic fluid: This can provide information on color, odor, and consistency, but it is of lower priority compared to the previous tasks.
4. Observe the perineum for umbilical cord prolapse: While important, this task has the lowest priority as it is less likely to occur immediately after amniotomy.