A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

Place the client in Trendelenburg position during the procedure.

Instruct the client to maintain a full bladder for the procedure.

Administer a tocolytic 30 min before the procedure.

Monitor the fetal heart rate throughout the procedure.

Answer and Explanation

The Correct Answer is D

A. Place the client in Trendelenburg position during the procedure – Incorrect, as amniocentesis is typically performed with the client in a supine position.

B. Instruct the client to maintain a full bladder for the procedure – This is required for an early pregnancy amniocentesis (before 20 weeks), but for later procedures, the bladder should be empty.

C. Administer a tocolytic 30 min before the procedure – Not routinely necessary unless the client is at risk for preterm labor.

D. Monitor the fetal heart rate throughout the procedure – Correct, as amniocentesis carries a risk of fetal distress, and continuous monitoring ensures immediate detection of complications.

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Correct Answer is D

Explanation

A. Fried chicken – High-fat foods like fried chicken relax the lower esophageal sphincter (LES), worsening GERD symptoms.

B. Tomato soup – Acidic foods like tomatoes can irritate the esophagus and should be avoided.

C. Hot cocoa – Chocolate and caffeine-containing drinks relax the LES and increase acid production, worsening GERD.

D. Bran cereal – This is a good choice because high-fiber foods promote digestion and help reduce acid reflux.

A. Lubricate the catheter with water-soluble gel. B. Attach a prefilled syringe to the indwelling catheter inflation hub C. Cleanse the client's meatus with antiseptic solution. D. Position the client with her knees flexed and legs apart.

Correct Answer is D

Explanation

A. Close the doors and windows on the unit – While containing the fire is important, it is not the first priority. Activating the fire alarm ensures facility-wide response and safety protocols.

B. Activate the fire alarm system – This is the first action because it alerts emergency responders and allows evacuation protocols to begin. Timely activation prevents the fire from spreading and ensures prompt intervention.

C. Obtain and use a fire extinguisher – Fire extinguishers are used only for small, contained fires and should be handled by trained personnel after activating the alarm.

D. Evacuate clients from the area – While evacuation is critical, activating the fire alarm ensures a coordinated evacuation plan rather than causing panic.

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A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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