A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Instruct the client to be NPO for six hours prior to the procedure

Instruct the client to maintain a full bladder for the procedure

Monitor the fetal heart rate prior to the procedure.

Place the client in Trendelenburg position during the procedure

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.

B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.

C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.

D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.

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Correct Answer is C

Explanation

Rationale:

A. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to sympathetic nervous system blockade, not hypertension. Monitoring for hypotension is more appropriate.

B. Have protamine sulfate available at the bedside: Protamine sulfate is the antidote for heparin, not epidural anesthesia. It has no relevance in managing epidural-related effects during labor.

C. Reposition the client side-to-side each hour: Changing positions frequently helps promote venous return, enhance placental perfusion, and reduce the risk of pressure injuries and aortocaval compression from a supine position.

D. Decrease the maintenance infusion rate of IV fluid: IV fluids are typically increased before and during epidural anesthesia to prevent or manage hypotension, not decreased. Reducing the rate could worsen hypotension.

A. Rotate staff members caring for the client. B. Mix the medication with the client's food items. C. Speak in a neutral tone when addressing the client D. Limit the client's opportunities to socialize with others

Correct Answer is C

Explanation

Rationale:

A. Rotate staff members caring for the client: Clients with paranoid personality disorder often struggle with trust and may become more suspicious if care is inconsistent. Assigning consistent staff helps build therapeutic rapport and minimizes perceived threats.

B. Mix the medication with the client’s food items: Covertly administering medications violates the client’s autonomy and can worsen paranoia if discovered. Open, honest communication is essential when working with clients who have paranoid thoughts.

C. Speak in a neutral tone when addressing the client: A neutral, calm, and nonjudgmental tone reduces perceived hostility or manipulation. It supports the development of trust and helps avoid triggering defensive or suspicious behaviors.

D. Limit the client’s opportunities to socialize with others: Social interaction should not be restricted unless it poses a safety risk. Encouraging appropriate socialization may help reduce isolation and reinforce reality, even if the client has difficulty with interpersonal relationships.

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A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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