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What sign(s) of infection should the nurse assess for after an amniotomy?
- A. Oral temperature of 37?°C (99.8?°F)
- B. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute
- C. Flecks of vernix in the amniotic fluid
- D. Low back pain
Correct Answer: B
Rationale: Increase in the FHR above 160 beats/minute frequently precedes a woman's temperature elevation, indicating possible infection.
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What will the nurse expect when caring for this patient?
- A. Elevated uterine resting tone
- B. Painful and poorly coordinated contractions
- C. Implementation of fluid restriction
- D. Use of frequent position changes
Correct Answer: D
Rationale: A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions.
What nursing assessment should be reported immediately after an amniotomy?
- A. Fetal heart rate is regular at 154 beats/minute.
- B. Amniotic fluid is clear with flecks of vernix.
- C. Amniotic fluid is watery and pale green.
- D. Maternal temperature is 37.8?°C.
Correct Answer: C
Rationale: Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.
What should the nurse assess for in the newborn?
- A. Loss of hair from contact with forceps
- B. Sacral hematoma
- C. Facial asymmetry
- D. Shoulder dislocation
Correct Answer: C
Rationale: Pressure from forceps may injure the infant's facial nerve, which is evidenced by facial asymmetry.
What complication should the nurse closely assess for with this patient?
- A. Chorioamnionitis
- B. Hemorrhage
- C. Hypotension
- D. Amniotic fluid embolism
Correct Answer: A
Rationale: Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture, because the barrier to the uterine cavity is broken.
What side effect should the nurse inform the patient that she might experience?
- A. Nausea and vomiting
- B. Headache
- C. Warm flush
- D. Urinary frequency
Correct Answer: C
Rationale: Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.