What assessment must the nurse make immediately after an amniotomy?

Correct Answer: C

Rationale: Immediately after an amniotomy, which is the artificial rupture of the amniotic sac, the nurse's priority assessment should be the fetal heart rate (FHR). This is because amniotomy can cause changes in the fetal heart rate due to changes in the intrauterine environment. Monitoring the FHR helps to ensure the well-being of the fetus and detect any signs of fetal distress promptly. Option A, maternal blood pressure, is important to monitor during labor, but it is not the most immediate assessment after an amniotomy. Changes in maternal blood pressure may occur later and are not as directly impacted by the procedure. Option B, maternal pulse, is also important to monitor during labor, but it is not the most immediate assessment after an amniotomy. Changes in maternal pulse may occur later and are not as directly impacted by the procedure. Option D, fetal fibronectin level, is not typically assessed immediately after an amniotomy. Fetal fibronectin is a protein that may be tested to predict preterm labor, but it is not an immediate assessment that is needed after an amniotomy. Monitoring the FHR is more critical for immediate assessment in this situation.

Correct Answer: C

Rationale: Choice A is incorrect because the client's contractions being further apart (7 minutes) compared to earlier (5 minutes) indicates that labor is not progressing, as contractions should typically become closer together as labor intensifies. Choice B is incorrect because the client stating that she can talk through contractions easier after taking a walk suggests that the contractions may not be strong or frequent enough to indicate active labor. In active labor, contractions typically become more intense and difficult to talk through. Choice D is incorrect because the client mentioning tightening late afternoon and still feeling it after a nap does not necessarily indicate active labor. These symptoms could be attributed to Braxton Hicks contractions or false labor, which do not indicate that true labor has begun. Choice C is the correct answer because the client stating that contractions hurt more after taking a shower suggests that the contractions are becoming more intense and frequent, which are typical signs of active labor. The increase in pain and intensity of contractions after physical activity like a shower can indicate that labor is progressing.

Correct Answer: D

Rationale: Seeing the fetal head through the vaginal introitus indicates that the baby is descending through the birth canal and is close to being born. Therefore, the correct answer is D: "The baby is almost crowning." This statement accurately describes the position of the baby in relation to the birth process. Option A: "The baby's head is engaged." This statement refers to the baby's head being fixed in the mother's pelvis, not necessarily close to being born. While engagement is a positive sign of progress in labor, it does not indicate that the baby is almost crowning. Option B: "The baby is floating." This statement suggests that the baby is not yet engaged in the pelvis and is still floating freely. This is an incorrect statement as seeing the fetal head through the vaginal introitus indicates the baby is well descended and not floating. Option C: "The baby is at the ischial spines." This statement refers to the baby being at the level of the ischial spines in the pelvis. While this is a common landmark used to assess fetal descent, it does not necessarily mean that the baby is almost crowning. Seeing the fetal head through the vaginal introitus indicates the baby is further along in the birth process. In conclusion, the correct answer is D because it accurately describes the baby's position in relation to the birth process when the fetal head is seen through the vaginal introitus.

Correct Answer: B

Rationale: Option B is the correct answer because it acknowledges the client's feelings as normal during early pregnancy. It is essential for the nurse to validate the client's emotions and provide reassurance that it is common to have mixed feelings about pregnancy, especially during the first trimester. By normalizing the client's feelings, the nurse can establish a trusting and supportive relationship, which is crucial for effective communication and care. Option A is incorrect because it jumps to informing the provider without first addressing the client's feelings directly. While it is important to involve the provider if necessary, the immediate focus should be on addressing the client's emotions and providing support. Option C is incorrect because it dismisses the client's concerns and puts pressure on them to feel a certain way about their pregnancy. It is not helpful or therapeutic to tell the client how they should be feeling, as this can invalidate their emotions and create additional stress. Option D is incorrect because it assumes that the client needs counseling without first exploring their feelings and offering support. While counseling may be beneficial for some clients, it is important to first address the client's emotions and validate their experiences before making such a recommendation.

Correct Answer: D

Rationale: At 40 weeks gestation, the fundal height is typically at the xiphoid process. This is because as the pregnancy progresses, the uterus expands and grows upwards towards the diaphragm. Palpating the fundal height at the xiphoid process allows the healthcare provider to assess the growth and position of the fetus in relation to the expected landmarks in the abdomen. Choice A: Palpating the fundal height directly above the symphysis pubis would be more indicative of a much earlier gestational age, around 12-14 weeks, when the fundus is still within the pelvic cavity. Choice B: Palpating the fundal height between the umbilicus and xiphoid process is typically seen around 20-22 weeks gestation. At 40 weeks, the fundus should have risen above the umbilicus. Choice C: Palpating the fundal height at the umbilicus is more indicative of a gestational age around 20-22 weeks. By 40 weeks, the fundus should have surpassed the umbilicus. Therefore, the correct answer is D, palpating the fundal height at the xiphoid process, as this is where it is expected to be at 40 weeks gestation.