A patient is to have an amniotomy to induce labor. The nurse recognizes that the priority intervention following the amniotomy is to:
1. apply clean linens under the woman.
2. take the patient's vital signs.
3. perform a vaginal exam.
4. assess the FHR.
4
1. Incorrect. Providing comfort measures for the patient is important, but it is not the priori-ty immediately following an amniotomy.
2. Incorrect. The woman's temperature should be checked every 2 hours following AROM, but this is not the priority at this time.
3. Incorrect. The woman would have had a vaginal exam during the procedure. Unless there is suspicion of a cord prolapse, a vaginal exam is not warranted. Additionally, FHR assess-ment would provide clinical cues to a prolapsed cord.
4. Correct. The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse.
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