A nurse is caring for a client who had an amniocentesis at 16 weeks gestation and reports cramping and vaginal bleeding 24 hours later.
Which of the following actions should the nurse take first?
Administer Rho(D) immune globulin.
Monitor fetal heart rate
Assess maternal vital signs
Obtain an order for an ultrasound exam.
The Correct Answer is B
The correct answer is choice B. Monitor fetal heart rate.
This is because cramping and vaginal bleeding after amniocentesis are signs of possible complications such as miscarriage, preterm labor, or injury to the fetus.
Monitoring fetal heart rate can help assess the well-being of the fetus and detect any signs of distress.
Choice A is wrong because administering Rho(D) immunoglobulin is only necessary if the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause Rh sensitization.
This is not given routinely to all women who have amniocentesis.
Choice C is wrong because assessing maternal vital signs is not the first priority when there is a risk of fetal compromise.
Maternal vital signs can be affected by many factors and are not specific indicators of fetal health.
Choice D is wrong because obtaining an order for an ultrasound exam is not the first action to take.
An ultrasound exam can help confirm the diagnosis of complications such as placental abruption or fetal demise, but it requires time and equipment that might delay immediate intervention.
Monitoring fetal heart rate can be done quickly and easily at the bedside.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because AFP levels vary according to the gestational age of the fetus, and reporting them as multiples of the median (MoM) allows for a standardized comparison.
Choice B is wrong because AFP results do not differentiate between neural tube defects and chromosomal abnormalities.
They only indicate an increased risk for these conditions, which need further testing to confirm.
Choice C is wrong because AFP results do not assess the risk of fetal demise or multiple gestation.
They only measure the amount of AFP in the maternal blood, which can be affected by various factors such as maternal weight, race, diabetes, and fetal anomalies.
Choice D is wrong because AFP results are reported as MoM regardless of factors such as maternal weight and race.
These factors are taken into account when calculating the MoM value, which adjusts for the expected variation in AFP levels among different populations.
Normal ranges for AFP MoM vary depending on the laboratory and the method used, but generally they are between 0.5 and 2.52.
Values above or below this range may indicate an increased risk for certain fetal conditions or complications.
Correct Answer is B
Explanation
Choice A is wrong because it describes a transabdominal CVS procedure, which involves a needle instead of a catheter.
Choice C is wrong because it describes a procedure that is not used for CVS.A needle inserted through the cervix could damage the fetal membranes or cause bleeding.
Choice D is wrong because it describes a procedure that is not possible.A catheter cannot be inserted through the abdomen and uterus into the placenta.
Normal ranges for CVS are not applicable as it is a diagnostic test, not a screening test.
It provides a definitive result of whether the fetus has a chromosomal abnormality or a genetic disorder.CVS is usually done between 10 and 13+6 weeks of pregnancy.
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