A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

Correct Answer: B

Rationale: The priority nursing action following an amniotomy (rupture of the amniotic sac) is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress or complications that may arise after the procedure. Changes in the fetal heart rate pattern can indicate the need for interventions to ensure the well-being of the fetus. Observing the color and consistency of the amniotic fluid, assessing the client's temperature, and evaluating for the presence of chills and increased uterine tenderness are also important assessments following amniotomy, but assessing the fetal heart rate takes precedence in this situation to ensure the safety of the fetus.

Correct Answer: A

Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.

Correct Answer: D

Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.

Correct Answer: D

Rationale: In the scenario of a postpartum mother reporting a severe headache, the immediate action the nurse should take is to notify the healthcare provider immediately (Option D). This is the correct choice because a severe headache postpartum could be indicative of serious conditions such as postpartum preeclampsia or postpartum hemorrhage, both of which require prompt medical attention. Administering analgesics and monitoring blood pressure (Option A) could mask important symptoms and delay the necessary medical evaluation. Encouraging the mother to rest (Option B) is not appropriate when a severe headache could be a sign of a potentially life-threatening condition. Applying a cold compress (Option C) may provide temporary relief but does not address the underlying cause of the severe headache. In an educational context, it is crucial for nurses to recognize the potential complications that can arise postpartum and to prioritize prompt communication with healthcare providers when patients present with concerning symptoms. This case emphasizes the importance of timely assessment and intervention in the postpartum period to ensure the well-being of both the mother and the newborn.

Correct Answer: A

Rationale: In the context of a newborn with a temperature of 35.5°C (95.9°F), the priority nursing action is to place the newborn under a radiant warmer (Option A). This is because newborns have limited ability to regulate their body temperature, and hypothermia can lead to serious complications such as respiratory distress, hypoglycemia, and metabolic acidosis. Placing the newborn under a radiant warmer helps to prevent further heat loss and stabilize the infant's temperature. Administering warm IV fluids (Option B) is not the priority in this situation as direct warming of the newborn is more effective in addressing hypothermia. Swaddling the newborn in warm blankets (Option C) may provide some insulation but may not be sufficient to rapidly raise the infant's temperature. Providing glucose supplementation (Option D) is not indicated as the primary concern in this scenario is to address the hypothermia promptly to prevent further complications. In an educational context, understanding the significance of maintaining newborn thermoregulation is crucial for nursing practice in maternal newborn care. Nurses need to be able to recognize signs of hypothermia in newborns and take prompt action to address it, as even mild hypothermia can have detrimental effects on a newborn's health and wellbeing. Placement under a radiant warmer is a standard intervention to stabilize the newborn's temperature quickly and prevent complications associated with hypothermia.