Physiological Integrity Q 37
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
A. Degree of cervical dilation
B. Fetal heart tones
C. Client’s vital signs
D. Client’s level of discomfort
Correct Answer: B. Fetal heart tones
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. The nurse plays a vital role during the procedure in monitoring the mother as well as the fetus, she also notes the color of the draining amniotic fluid and documents the findings in the medical chart.
Option A: Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The two most commonly used devices are (1) an approximately 10-inch rod with a hook on the end of the rod or (2) a finger cot with a hook on the end of the cot. With either device, the practitioner assesses cervical dilation through the performance of a sterile digital exam.
Option C: After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider.
Option D: After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort. The nurse needs to frequently change underpads. One of the most crucial roles of the nurse is to educate the woman about the amniotomy procedure and address the patient’s concerns at all times.