The nurse assists while a pregnant patient has an amniotomy. Which action should the nurse take immediately at the conclusion of the procedure?
A) Assess fetal heart rate.
B) Adjust intravenous fluid infusion rate.
C) Assist the patient to wash the perineum.
D) Provide clean gown and linens for the patient.
A
Feedback:
Amniotomy is the artificial rupturing of membranes during labor. A disadvantage of amniotomy is it puts a fetus momentarily at risk for cord prolapse if a loop of cord escapes into the vagina with the fluid. Always measure the fetal heart rate immediately after the rupture of membranes to determine this did not occur. The nurse can assist the patient with washing and applying a clean gown and linens after the fetal heart rate is assessed. The patient may or may not have an intravenous infusion at this time.
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