A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)
Explanation & Rationale
A. Obtain a baseline reading of the FHR and contraction pattern. Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy. D. Position the client with a rolled towel under her hips. Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning. C. Pass the sterile hook to the provider. The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure. E. Check the fluid for color, odor, and consistency. After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection. B. Document the procedure in the electronic medical record. The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.