A nurse is preparing to perform an amniocentesis on a client who is at 27 weeks of gestation and has pre-term labor.
Which of the following actions should the nurse take before the procedure?
Administer tocolytic medication to stop contractions
Instruct the client to empty her bladder
Obtain informed consent from the client
Monitor fetal heart rate and activity
The Correct Answer is B
Instruct the client to empty her bladder. This is because a full bladder can interfere with the insertion of the needle and increase the risk of injury to the bladder or the uterus. Emptying the bladder also reduces discomfort during the procedure.
Choice A is wrong because administering tocolytic medication to stop contractions is not necessary before amniocentesis. Tocolytic medication can have side effects and should only be used when there is a clear indication of preterm labor.
Choice C is wrong because obtaining informed consent from the client is not a nursing action, but a medical one. The nurse can assist in providing information and answering questions, but the final consent should be obtained by the doctor who will perform the procedure.
Choice D is wrong because monitoring fetal heart rate and activity is not a specific action before amniocentesis, but a routine part of prenatal care. Fetal heart rate and activity can be affected by many factors, such as maternal position, fetal sleep cycle, or maternal blood sugar level.
Monitoring them before amniocentesis does not provide any useful information for the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Thromboembolism.
Prolonged bed rest increases the risk of venous stasis and blood clot formation in the lower extremities, which can lead to pulmonary embolism if the clot dislodges and travels to the lungs.
This is a life-threatening complication that requires immediate treatment.
Choice B. Placental abruption is wrong because it is not caused by bed rest, but by trauma, hypertension, cocaine use, or other factors that can cause the placenta to separate from the uterine wall.
Choice C. Uterine atony is wrong because it is not caused by bed rest, but by overdistension of the uterus, prolonged labor, infection, or other factors that can impair the contraction of the uterine muscles after delivery.
Choice D. Infection is wrong because it is not caused by bed rest, but by poor hygiene, invasive procedures, or other factors that can introduce microorganisms into the reproductive tract.
Normal ranges for maternal heart rate are 60-100 beats per minute and blood pressure are 110-140/60-90 mm Hg.
Normal range for fetal heart rate is 110-160 beats per minute.
Correct Answer is A
Explanation
Ultrasound.
An ultrasound can help determine the gestational age, fetal growth, placental location, and amniotic fluid volume of the fetus.
These factors can affect the risk of pre-term labor and delivery.
An ultrasound can also detect cervical changes that may indicate pre-term labor.
Choice B is wrong because a blood count is not specific for pre-term labor.
It may be done to check for anemia, infection, or other conditions that may affect the pregnancy, but it does not directly assess the risk of pre-term labor.
Choice C is wrong because a urine culture is not specific for pre-term labor.
It may be done to check for urinary tract infection, which can cause pre-term labor, but it does not directly assess the risk of pre-term labor.
Choice D is wrong because an amniocentesis is not usually done for pre-term labor.
It may be done to check for fetal lung maturity, chromosomal abnormalities, or infections, but it is an invasive procedure that carries some risks and complications.
It does not directly assess the risk of pre-term labor.
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