A nurse is caring for a patient who is at 15 weeks gestation, is rh-negative, and just had an Amniocentesis.
Which of the following interventions is the nurse’s priority following the procedure?
Check Pt.'s temp.
Observe for UC’s.
Administer Rho-Immunoglobulin.
Monitor the FHR.
The Correct Answer is D
A.Checking the patient’s temperature is not the priority intervention following an amniocentesis. Temperature may be monitored to detect infection.
B. Amniocentesis can irritate the uterus and occasionally precipitate cramping or contractions; nurses should watch for increasing uterine activity or vaginal bleeding and report these findings.
C. RhIg should be given within the recommended window (within 72 hours, ideally sooner), to prevent the risk of hemolytic disease of the newborn in subsequent pregnancies.
D. Immediate fetal monitoring (FHR and maternal vitals) is commonly performed after amniocentesis to detect acute fetal distress or complications; several centers observe FHR for a period after the procedure. This is an important immediate safety action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Checking the patient’s temperature is not the priority intervention following an amniocentesis. Temperature may be monitored to detect infection.
B.Amniocentesis can irritate the uterus and occasionally precipitate cramping or contractions; nurses should watch for increasing uterine activity or vaginal bleeding and report these findings.
C.RhIg should be given within the recommended window (within 72 hours, ideally sooner), to prevent the risk of hemolytic disease of the newborn in subsequent pregnancies.
D.Immediate fetal monitoring (FHR and maternal vitals) is commonly performed after amniocentesis to detect acute fetal distress or complications; several centers observe FHR for a period after the procedure. This is an important immediate safety action.
Correct Answer is C
Explanation
The client has a history of bleeding disorders.
This is because amniocentesis is an invasive procedure that involves passing a needle through the abdomen and into the uterus to collect a sample of amniotic fluid.This can cause bleeding and increase the risk of miscarriage.
A client with a bleeding disorder may have difficulty clotting and may experience excessive bleeding after the procedure.
Choice A is wrong because asthma is not a contraindication for amniocentesis.
Asthma is a chronic lung condition that causes inflammation and narrowing of the airways.
It does not affect the ability to perform amniocentesis or the risk of complications.
Choice B is wrong because diabetes is not a contraindication for amniocentesis.
Diabetes is a condition that affects how the body uses glucose, a type of sugar that is the main source of energy for cells.
It does not affect the ability to perform amniocentesis or the risk of complications.
Choice D is wrong because hypertension is not a contraindication for amniocentesis.
Hypertension is a condition that causes high blood pressure, which can damage the heart and blood vessels.
It does not affect the ability to perform amniocentesis or the risk of complications.
Normal ranges for blood pressure are less than 120/80 mmHg, for blood glucose are 70-130 mg/dL before meals and less than 180 mg/dL after meals, and for clotting time are 8-15 minutes.
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