A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?
Empty her bladder immediately prior to the procedure.
Refrain from eating breakfast on the day of the procedure.
Give herself a hypertonic enema the day before the procedure.
Wash her abdomen with soap and water the morning of the procedure.
The Correct Answer is A
Choice A rationale: An amniocentesis involves inserting a needle through the abdominal wall into the amniotic sac to obtain a sample of amniotic fluid. Emptying the bladder before the procedure reduces the risk of bladder puncture during the process.
Choice B rationale: Fasting is not typically necessary for an amniocentesis. It is generally done on an outpatient basis, and fasting is not required.
Choice C rationale: An enema is not necessary before an amniocentesis and is not part of the standard preparation.
Choice D rationale: While cleanliness is important, this instruction is not specific to an amniocentesis and is not a standard pre-procedure requirement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Placing elbow restraints is not a recommended practice for preterm newborns. Restraints are used in some cases to prevent the baby from pulling on tubes or lines, but it is not primarily for energy conservation.
Choice B rationale: While frequent position changes are important to prevent pressure ulcers and promote comfort, they may not necessarily help conserve energy in a preterm newborn.
Choice C rationale: Preterm newborns have limited energy reserves, and conserving energy is essential for their growth and development. Clustering care activities involves combining nursing care tasks to allow for longer periods of uninterrupted rest for the baby. This approach reduces the baby's energy expenditure and promotes better weight gain and stability.
Choice D rationale: While gentle touch and massage can be beneficial for preterm newborns to promote bonding and relaxation, it may not directly conserve energy as cluster care does.
Correct Answer is B
Explanation
Choice A rationale:
Administering the hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is not the appropriate treatment for a newborn whose mother is positive for the hepatitis B surface antigen. Immediate intervention is required to prevent transmission.
Choice B rationale:
The newborn of a mother who is positive for the hepatitis B surface antigen should receive hepatitis B immune globulin (HBIG) and the hepatitis B vaccine within 12 hours of birth. HBIG provides passive immunity to the baby while the vaccine stimulates active immunity.
Choice C rationale:
Administering hepatitis B immune globulin for 1 week followed by the hepatitis B vaccine monthly for 6 months is not the correct treatment plan. Immediate intervention is necessary to prevent transmission to the newborn.
Choice D rationale:
Administering the hepatitis B vaccine at 24 hours followed by hepatitis B immune globulin every 12 hours for 3 days is not the appropriate treatment. Hepatitis B immune globulin should be given within 12 hours of birth, not over several days.
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