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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Feeding a formula every 2 hours is not recommended and may lead to overfeeding. Newborns generally feed on demand, and the frequency of feeding can vary.
Choice B rationale: Breastfed newborns may have more frequent bowel movements, sometimes after each feeding. Two to three stools per day would be on the lower side of the normal range for breastfed infants.
Choice C rationale: Breastfeeding newborns typically need to feed frequently to establish a good milk supply and ensure adequate nutrition. Newborns often feed about 8 to 12 times in a 24-hour period, which translates to approximately five to seven times during the day and night.
Choice D rationale: Formula-fed newborns typically have more regular bowel movements compared to breastfed babies. Expecting only one stool every three days in a formula-fed newborn could indicate constipation, and it is not the expected norm.
Correct Answer is D
Explanation
Choice A rationale:
Massaging the area is not recommended because the client's symptoms could indicate a possible deep vein thrombosis (DVT), and massaging could dislodge a clot and cause harm.
Choice B rationale:
Applying cold compresses is not recommended if DVT is suspected, as it could potentially worsen the condition.
Choice C rationale:
Flexing the knee while resting is not recommended if DVT is suspected, as it could potentially worsen the condition and increase the risk of a clot traveling to the lungs (pulmonary embolism).
Choice D rationale:
Elevating the leg can help reduce swelling and improve blood flow. However, the client should still see the provider for further evaluation of possible DVT.
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