NursingPlex
    Sign In
    Vati PN Comprehensive Predictor Proctored Exam

    A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

    Explanation & Rationale

    A. Amniotic fluid color: Assessing amniotic fluid color is important to identify meconium-stained or bloody fluid, which can indicate fetal compromise or infection. While this provides valuable information, it does not provide immediate data about fetal well-being, making it secondary to continuous fetal monitoring. B. The client's temperature: Maternal temperature is monitored to detect infection, especially after rupture of membranes. However, fever develops over time, so it is not the most immediate priority immediately following amniotomy. Early assessment focuses on detecting acute fetal compromise. C. Frequency of contractions: Monitoring contraction frequency, duration, and intensity is essential for assessing labor progress. While contraction patterns guide labor management, fetal response to contractions is a higher priority after membrane rupture, as sudden changes can affect fetal oxygenation. D. Fetal heart rate: Fetal heart rate assessment is the priority immediately after an amniotomy because sudden changes in amniotic fluid volume, umbilical cord prolapse, or cord compression can compromise fetal oxygenation. Early identification of decelerations or abnormal patterns allows rapid intervention to prevent fetal injury.

    🔒 Submit your answer to reveal