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 B

Explanation

A. ECT does not typically affect a client’s voice.

B. This is the correct answer. A common side effect of ECT is short-term confusion and memory impairment, which can last for minutes to a few hours after the procedure.

C. Most clients wake up within a few minutes, not 30 minutes.

D. Clients do not typically feel pulsations in the neck during the procedure since they are under anesthesia and muscle relaxants are used.

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears. B. Place a vibrating tuning fork on the top of the child's head. C. Whisper a statement to the child from 0.6 m (2 feet) away. D. Apply a pair of headphones securely over the child's ears

Correct Answer is B

Explanation

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

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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?

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