A nurse is assisting with an amnioinfusion. What critical nursing actions are included in this procedure? (Select all that apply.)
A.
Assessing the maternal temperature
B.
Assembling equipment
C.
Documenting fluid exiting the vagina
D.
Maintaining sterile technique
E.
Monitoring the fetal heart rate
ANS: A, B, C, E
The critical nursing actions during this procedure are assembling the equipment; monitoring the fetal heart rate, contraction status, and maternal temperature; and verifying and documenting that the infused fluid exits the vagina. The nurse is not performing the procedure; it is up to the provider to maintain sterile technique. Of course the nurse should be vigilant that sterile technique is not breached.
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