A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis.
The client asks why she is having an ultrasound prior to the procedure.
Which of the following responses by the nurse is appropriate?
"This is a screening tool for spina bifida.”.
"It is useful for estimating fetal age.”.
"It assists in identifying the location of the placenta and fetus.”.
"This will determine if there is more than one fetus.”. .
The Correct Answer is C
Choice A rationale:
"This is a screening tool for spina bifida.”. This statement is incorrect. An ultrasound performed before an amniocentesis is not primarily used as a screening tool for spina bifida. Spina bifida can be detected through other diagnostic tests.
Choice B rationale:
"It is useful for estimating fetal age.”. While ultrasounds can provide information about fetal age, it is not the primary reason for performing an ultrasound before an amniocentesis. The main purpose is to identify the location of the placenta and fetus, which is essential for safely performing the amniocentesis procedure.
Choice C rationale:
"It assists in identifying the location of the placenta and fetus.”. This is the correct answer. An ultrasound before amniocentesis is crucial for locating the fetus and the placenta accurately. This information helps healthcare providers ensure the safe and precise insertion of the needle into the amniotic sac.
Choice D rationale:
"This will determine if there is more than one fetus.”. Determining if there is more than one fetus is an important aspect of prenatal care but is not the primary reason for performing an ultrasound before amniocentesis. It is generally confirmed through earlier ultrasounds during routine prenatal care. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The normal sequence of postpartum vaginal discharge, known as lochia, follows this order:
D. Lochia rubra, lochia serosa, lochia alba.
Here's a quick breakdown:
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Lochia rubra (Days 1–4): Bright red discharge with blood, mucus, and tissue.
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Lochia serosa (Days 4–10): Pinkish or brownish discharge as bleeding slows.
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Lochia alba (Days 10–6 weeks): Yellowish-white discharge as the body completes healing.
Correct Answer is A
Explanation
Answer and explanation
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform? The correct answer is Choice A: Report the client's temperature elevation.
Choice A rationale:
The nurse should report the client's temperature elevation because a temperature of 37.7°C (100°F) is above the normal range for a postpartum client. A postpartum temperature greater than 100.4°F (38°C) may indicate an infection, such as endometritis or mastitis. It is essential to identify and treat infections promptly to prevent complications.
Choice B rationale:
Asking the client to empty her bladder is not the most appropriate action in this situation. While bladder distention can sometimes cause uterine displacement, the elevated temperature is a more urgent concern. The nurse should address the temperature issue first.
Choice C rationale:
Increasing IV fluids is not indicated based on the information provided. The client's temperature elevation and soft breasts are concerning, and increasing IV fluids will not address these issues. It's essential to focus on the potential infection first.
Choice D rationale:
Encouraging the client to nurse more frequently to stimulate milk production is not the priority in this scenario. While breastfeeding is essential for milk production and uterine involution, the client's elevated temperature and other findings should be addressed first.
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