A client at 20 weeks gestation reports discomfort after amniocentesis procedure to the nurse. Which of the following assessment findings warrants priority action by the nurse?
Braxton Hicks contraction
Amniotic fluid contains fetal urine
Prolonged vaginal bleeding
Lab results reveal abnormal chromosome cells
The Correct Answer is C
Explanation:
A. Braxton Hicks contraction
Braxton Hicks contractions are often referred to as "practice" contractions and are common during pregnancy. They are typically irregular and do not cause cervical changes. While discomfort after an amniocentesis procedure can sometimes trigger Braxton Hicks contractions, they are not usually a cause for immediate concern unless they become frequent, intense, or are accompanied by other signs of preterm labor, such as regular contractions, lower back pain, pelvic pressure, or changes in vaginal discharge.
B. Amniotic fluid contains fetal urine
The presence of fetal urine in the amniotic fluid is a normal and expected process during pregnancy. Fetal urine production contributes to the volume and composition of amniotic fluid, helping maintain the environment in the uterus and supporting fetal development. This finding is not directly related to the client's discomfort after an amniocentesis procedure and is not a cause for immediate concern unless there are other complications or abnormalities related to the amniotic fluid composition.
C. Prolonged vaginal bleeding
Prolonged vaginal bleeding after an amniocentesis procedure is a significant finding that requires immediate attention. While some spotting or mild bleeding can occur after the procedure, prolonged or significant bleeding may indicate complications such as uterine injury, placental abruption, or other issues that need urgent assessment and intervention by healthcare providers.
D. Lab results reveal abnormal chromosome cells
Abnormal chromosome cells found in the amniotic fluid sample obtained during amniocentesis may indicate genetic abnormalities or conditions in the fetus. While this finding is significant and requires follow-up and further evaluation, it is not an immediate concern in terms of the client's discomfort or the need for priority action by the nurse unless it is associated with other urgent clinical signs or symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation:
A. Acarbose:
Acarbose is an oral antidiabetic medication that works by slowing down the digestion and absorption of carbohydrates in the intestines. It is typically used in the management of type 2 diabetes but is not commonly prescribed for gestational diabetes mellitus (GDM). Acarbose is not usually recommended during pregnancy, especially since there are other safer options available for managing GDM.
B. Repaglinide:
Repaglinide is another oral antidiabetic medication that stimulates insulin release from the pancreas. While it is effective in lowering blood sugar levels, it is not commonly used as a first-line treatment for gestational diabetes. Repaglinide may have a more rapid onset of action compared to other oral antidiabetic drugs, but its use during pregnancy is not as common as other medications like glyburide or insulin.
C. Glipizide:
Glipizide is an oral sulfonylurea medication used primarily in the management of type 2 diabetes. It stimulates insulin secretion from the pancreas. However, like other sulfonylureas, glipizide is not typically recommended for use during pregnancy due to safety concerns for the developing fetus. It may also have a higher risk of hypoglycemia compared to other options.
D. Glyburide:
Glyburide is an oral sulfonylurea medication that helps lower blood sugar levels by stimulating insulin release from the pancreas. It is one of the commonly used medications for managing gestational diabetes when diet and exercise alone are not sufficient. Glyburide is generally considered safe for use during pregnancy, especially after the first trimester, and it has been found to effectively control blood glucose levels in many pregnant individuals with GDM.
Correct Answer is A
Explanation
Explanation:
A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."
This statement is correct. Around 12 weeks of pregnancy, the baby's heartbeat becomes audible using a Doppler stethoscope. This is a significant milestone in prenatal care as it allows healthcare providers and expectant parents to hear the baby's heartbeat for the first time, providing reassurance about fetal well-being.
B. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy."
This statement is incorrect. Lanugo, the fine hair covering the baby's body, typically appears much earlier in pregnancy, around 20 weeks. However, it usually starts to shed during the third trimester, and by week 36, the baby may have minimal or no lanugo remaining. Therefore, stating that lanugo covers the entire body by week 36 is inaccurate.
C. "The sex of the baby is determined by week 8 of pregnancy."
This statement is incorrect. The sex of the baby is determined at conception when the sperm fertilizes the egg. However, the external genitalia are not typically visible on ultrasound until around week 16 to 20 of pregnancy. Therefore, while the genetic sex is determined early, it may not be visualized or confirmed until later in pregnancy.
D. "You will first feel your baby move in week 24 of pregnancy."
This statement is incorrect. Most women begin to feel fetal movements, also known as quickening, between weeks 16 and 25 of pregnancy. The first movements are typically felt around weeks 18 to 20, rather than specifically at week 24. Therefore, stating that the first fetal movements are felt at week 24 is not accurate.
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