A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?
Irrigate the insertion site with sterile water before the procedure.
Administer Rh.(D) immune globulin after the procedure.
Position the client in a left lateral position during the procedure
Inform the client to be NPO for the procedure.
The Correct Answer is B
A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.
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Related Questions
Correct Answer is D
Explanation
A. Assessing cervical dilation is contraindicated due to risk of worsening bleeding with abruptio placenta.
B. Vaginal swabs for ferning test are used to assess rupture of membranes, not abruptio placenta.
C. Administering oxytocin can increase uterine contractions and worsen placental separation, so it is contraindicated.
D. Monitoring fetal heart rate tracings is essential to assess fetal well-being in cases of abruptio placenta.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A,B,C"}}
Explanation
- Vitamin B12 level: A B12 level of 159 pg/mL is below normal and consistent with pernicious anemia. This condition is caused by a lack of intrinsic factor, impairing B12 absorption in the gut. The client’s vegan diet may further reduce B12 intake, worsening deficiency.
- Fatigue: Fatigue results from decreased oxygen delivery to tissues due to low hemoglobin in all anemias. In sickle cell disease, abnormally shaped RBCs impair perfusion. Iron and B12 deficiencies impair RBC production, further contributing to fatigue.
- Ferritin level: Ferritin reflects the body’s iron storage, and a level of 8 ng/mL is below the normal range. Low ferritin confirms iron depletion, a hallmark of iron deficiency anemia. This can result from dietary lack or chronic inflammation, like in rheumatoid arthritis.
- Orthostatic hypotension: Orthostatic hypotension may occur with all anemias due to reduced circulating volume and poor oxygenation. Low hemoglobin and hematocrit lead to impaired vascular tone and autonomic response, causing dizziness or lightheadedness when standing.
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