The nurse is monitoring a patient who is receiving an amnioinfusion. Which assessments must the nurse perform to prevent a serious complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Color of amniotic fluid
2. Maternal blood pressure
3. Cervical effacement
4. Uterine resting tone
5. Fluid leaking from the vagina
2,4,5
Rationale 1: The color of the amniotic fluid is not a critical assessment.
Rationale 2: Blood pressure should be monitored along with other vital signs.
Rationale 3: Cervical effacement is not directly related to the amnioinfusion.
Rationale 4: The uterine resting tone should be carefully monitored with an internal pressure electrode.
Rationale 5: The nurse should continually check to make sure the infused fluid is being expelled from the vagina so it does not build up in the uterus and cause rupture.
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