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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Explanation:

A. Shortly after giving birth

This timing is not recommended for rubella immunization during pregnancy. Rubella vaccination should ideally occur before conception or during the postpartum period, but not immediately after giving birth.

B. Immediately

Immunization for rubella is not typically recommended immediately during pregnancy. It is preferred to administer rubella vaccination before pregnancy or during the postpartum period.

C. During her next attempt to get pregnant

This option is closer to the recommended timing. Women who lack immunity to rubella should receive the rubella vaccine after giving birth but before attempting to get pregnant again. This approach helps ensure protection against rubella during future pregnancies.

D. In the third trimester

Administering rubella immunization during the third trimester of pregnancy is not recommended. Vaccination against rubella should ideally occur either before pregnancy or after delivery, as giving it during pregnancy can pose risks to the fetus.

A. Slightly below the umbilicus B. 3 cm above the umbilicus C. 3 cm below the umbilicus D. Slightly above the umbilicus

Correct Answer is B

Explanation

Explanation:

A. Slightly below the umbilicus:

Around 16-20 weeks of gestation, the fundal height is typically palpated slightly below the umbilicus. This corresponds to the level of the fundus before it starts rising significantly above the umbilicus as the pregnancy progresses.

B. 3 cm above the umbilicus:

At 22 weeks of gestation, the fundal height is expected to be approximately 3 cm above the umbilicus. This is a common estimation for the fundal height at this stage of pregnancy, as the uterus continues to grow and the fundus ascends in a predictable manner.

C. 3 cm below the umbilicus:

Palpating the fundus 3 cm below the umbilicus would typically correspond to an earlier gestational age, such as around 16-18 weeks. As pregnancy advances, the fundal height increases, and by 22 weeks, it should be well above the level of the umbilicus.

D. Slightly above the umbilicus:

This location is closer to where the fundal height is expected to be at later gestational ages, such as 24-26 weeks. However, at 22 weeks of gestation, the fundal height should not be palpated slightly above the umbilicus but rather around 3 cm above it.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

Correct Answer is C

Explanation

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is B

Explanation

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