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 C

Explanation

A. The car seat should remain rear-facing until at least age 2, or until the child reaches the maximum height and weight limit specified by the manufacturer, not just until 12 months.
B. The retainer (chest) clip should be positioned at the level of the infant's armpits, not the abdomen, to ensure proper restraint.
C. Positioning the car seat at a 45° angle helps keep the infant’s airway open and reduces the risk of aspiration or airway obstruction.
D. For rear-facing seats, the harness straps should be at or below the baby's shoulders, not above.

A. Assist the client to empty their bladder. B. Apply oxygen at 2 L/min via nasal canula. C. Massage the client's fundus. D. Prepare to initiate cardiopulmonary resuscitation.

Correct Answer is D

Explanation

A. Emptying the bladder is not a priority during an amniotic fluid embolism (AFE) emergency.
B. Oxygen at 2 L/min is insufficient; high-flow oxygen or intubation may be necessary.
C. Fundal massage is used to control bleeding, not to treat AFE.
D. An amniotic fluid embolism can cause sudden cardiovascular collapse and respiratory failure; preparing to initiate cardiopulmonary resuscitation (CPR) is critical for survival.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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