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.

The active phase of labor occurs when the client is dilated 4–7cm. Active labor with more rapid cervical dilation generally starts around 6 centimeters of dilation. During the active phase, the cervix typically dilates at a rate of 1.2 to 1.5 centimeters per hour. Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation. The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions is considered the arrest of labor and may warrant clinical intervention.

Option B: The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement.
Option C: The transition phase of labor is 8–10cm in dilation. The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts.
Option D: The latent or early phase of labor is from 1cm to 3cm in dilation. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women respectively, without being considered prolonged.

The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Non-pharmacological care, like rooming-in and control of environmental factors, is the first clinical management strategy and should continue even after discharge from the hospital. Breastfeeding should be strongly encouraged unless there is maternal polysubstance abuse or maternal medical contraindication.

Option A: Treatment should always begin with non-pharmacological care while maintaining the mother-infant dyad and should continue even after discharge from the hospital. The goal of non-pharmacological treatment is to assist the self-organization of the neonate and support the neuronal-maturation. AAP has also recommended it as first-line in the management of NAS. These may include changes to the physical environment like darkening the room and quieting the surroundings, to decrease visual and auditory stimuli.
Option C: Placing the infant in an infant seat is incorrect because this will also cause movement that can increase muscle irritability. It is essential to understand that these infants have neurobehavioral dysfunction with disorganized behavior rather than adaptation problems. Because of this, individualizing the non-pharmacological care specific to the infant may be beneficial. Health care professionals should involve the mother and help her identify these interventions that alleviate the dysfunctional behaviors specific to her baby.
Option D: Teaching the mother to provide for early infant stimulation is incorrect because he is irritable and needs quiet and little stimulation at this time. Techniques such as gentle vertical rocking, side-lying C-position, containment with hands held, swaddling, and swaying can be soothing and may help reduce irritability and hypertonicity. Avoiding unnecessary tactile stimuli by clustering care and providing skin to skin is effective.

Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. Monitoring the patient’s hemodynamic status during and after the procedure is very important. The minimum monitors required are pulse oximeter for pulse and oxygen saturation as well as blood pressure cuff and continuous EKG to assess cardiovascular status.

Option A: The client can be checked for cervical dilation later after she is stable. A certified nurse presence is very important during and after the procedure to monitor the patient and baby (labor epidural analgesia) and to detect early signs of complications.
Option B: The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. The patient’s position plays a pivotal role in the procedure’s success. Epidural placement can be performed more commonly in a lateral decubitus and sitting position or less frequently in the prone position. In the lateral decubitus position, the patient is completely resting on their side on the bed surface, and the spine is parallel to that surface as well. Thighs and neck are flexed forward, imitating fetal position.
Option D: Fetal heart tones should be assessed after the blood pressure is checked. The physical exam focused on the spine is important to notice infection of the area and anatomical abnormalities or variations that can potentially affect the procedure. All the monitors must be placed and working, intravenous access placed, time out should take place before the procedure, and asepsis and antisepsis must be maintained. Risks must be discussed, and informed consent obtained.

The best way to prevent postoperative wound infection is hand washing. Up to 60% of SSI can be prevented. Prevention of postoperative wound infection is done by good general hygiene, operative sterility and effective barriers against transmission of infections, before, during and after surgery.

Option A: Use of prescribed antibiotics will treat infection, not prevent infections. The prophylaxis should only cover the current operating time and start at the beginning of anaesthesia (1A). The prophylaxis should reach high enough tissue doses before incision (1A). Short half-life preparations (e.g. cefalotin) must be followed up with a new dose if prolonged operating time.
Option C: Perform good hand hygiene throughout your stay. If bedridden, ask for wipes for hand disinfection. Ask visitors to carry out hand hygiene on arrival and when they leave the hospital. Ask health professionals to carry out hand hygiene if this fails—before and after your examination.
Option D: Asking the client to cover her mouth are good practices but will not prevent wound infections. Ensure the eradication of infections, urinary tract infections, skin infections, and other local infections prior to admission. Check the dental status, especially before larger elective interventions with implants and the like. Postpone surgery, if possible, until the infection is cleared.