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?
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.
Place the client in Trendelenburg position during the procedure.
The Correct Answer is C
Choice A rationale:
Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.
Choice B rationale:
Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.
Choice C rationale:
Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.
Choice D rationale:
Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should not include the client's frequency of call button use in the change-of-shift report. While this information might seem relevant, it can be misinterpreted and stigmatize the client. Sharing call button frequency without context could lead assumptions about the client being overly demanding or attention-seeking, instead of focusing on their potential needs and anxieties post-surgery.
Here's why the other options are acceptable to include:
- a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
- b. The client's most recent ventilator settings:Although the client is weaned, knowing their past ventilator settings provides valuable insight into their respiratory function and potential risks for decompensation.
- c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.
Therefore, the best answer is d. The frequency in which the client presses the call button.
Remember, a good change-of-shift report focuses on crucial clinical information relevant to the client's current condition and care plan, avoiding subjective observations that could lead to bias or misjudgment.
Correct Answer is A
Explanation
A - This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B - This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C - This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D - This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.
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