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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. A transvaginal fetal Doppler is not commonly used for continuous monitoring and is typically reserved for early pregnancy.
B. An external ultrasound transducer is appropriate for continuous fetal monitoring when the membranes are intact. It is noninvasive and safe for use during labor.
C. A DeLee Hillis fetoscope is used for intermittent auscultation, not continuous monitoring.
D. An internal fetal scalp electrode requires ruptured membranes and cervical dilation; it is contraindicated with intact membranes.

A. Administer an IV bolus of lactated Ringer's B. Monitor for clonus C. Obtain a prescription for misoprostol D. Restrict daily oral fluid intake.

Correct Answer is B

Explanation

A. IV fluids should be administered cautiously in preeclampsia to avoid fluid overload; an IV bolus is not routinely indicated.
B. Monitoring for clonus is important, as it is a sign of increased neuromuscular irritability and risk of seizure in preeclampsia.
C. Misoprostol is used to manage postpartum bleeding but is not specific to preeclampsia management.
D. Fluid restriction is generally not recommended unless there are signs of fluid overload or other complications.

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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?

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Naxlex Comprehensive Predictor Exams

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