Physiological Integrity Q 17
A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
A. Fetal heart tones 160bpm
B. A moderate amount of straw-colored fluid
C. A small amount of greenish fluid
D. A small segment of the umbilical cord
Correct Answer: B. A moderate amount of straw-colored fluid
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. This fluid usually is clear and odorless.
Option A: Fetal heart tones of 160 indicate tachycardia. Monitoring of the fetal heart rate as well as uterine activity can be easily obtained via external monitoring systems. However, in certain circumstances, more direct evaluation of the fetal heart rate or uterine activity is required during labor.
Option C: Greenish fluid is indicative of meconium. In certain circumstances, the fluid may either contain meconium or may be blood-tinged. It is important to note the color of the fluid at the time of rupture.
Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately. Typically, following artificial rupture of membranes, the practitioner should not immediately remove their hand from the vagina because it is at this point that the highest risk of potential cord prolapse can occur and will be noted as the amniotic fluid continues to drain. After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed.