A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis.
Which of the following information should the nurse include in the instructions?
"I will need to give you Rh(D) immune globulin because you are Rh positive.”
"You will need to have an empty bladder for the test.”
"You will have to lie on your left side during the test.”
"You will have to drink 50 grams of oral glucose before the test.”
The Correct Answer is B
Choice A rationale:
The administration of Rh(D) immune globulin (RhoGAM) is typically indicated for Rh-negative mothers who are carrying Rh-positive fetuses to prevent sensitization to Rh antigens. It is not directly related to the amniocentesis procedure. Therefore, this information is not necessary for the client undergoing an amniocentesis.
Choice B rationale:
This is the correct answer. Having an empty bladder is crucial during an amniocentesis procedure because a full bladder can obscure visualization of the fetus and the needle placement. It is essential for a successful and safe procedure. The nurse should instruct the client to empty their bladder before the test.
Choice C rationale:
The position during an amniocentesis is typically dorsal recumbent or semi-Fowler's position to allow for proper visualization of the fetus and needle placement. Lying on the left side is not a standard position for this procedure, so this information is incorrect and not necessary for the client.
Choice D rationale:
Drinking 50 grams of oral glucose is not a requirement for an amniocentesis procedure. This information is unrelated to the amniocentesis and can be confusing for the client. Therefore, it is not necessary to include this in the instructions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement, "You will no longer be infectious once you have completed a course of antibiotics," is incorrect. Genital herpes is a viral infection caused by the herpes simplex virus (HSV) Antibiotics do not treat viral infections, including herpes. Antiviral medications are used for herpes management, but they do not cure the infection. The virus can remain dormant in the body and reactivate.
Choice B rationale:
"You should increase fluid intake to relieve dysuria" is a correct and important piece of advice. Dysuria (painful urination) can be a symptom of genital herpes. Increasing fluid intake helps dilute urine, reducing discomfort during urination.
Choice C rationale:
"You should have the lesions drained as they appear" is incorrect. Lesion drainage is not a standard treatment for genital herpes. Antiviral medications are typically prescribed to manage outbreaks and reduce their duration and severity.
Choice D rationale:
"You should wear nylon underwear until the lesions have healed" is not the recommended guidance. Wearing loose-fitting cotton underwear is generally advised for comfort and to minimize irritation during a herpes outbreak. Nylon underwear may cause friction and discomfort.
Correct Answer is D
Explanation
Choice A rationale:
Hyperreflexia is not a common manifestation of Stevens-Johnson syndrome (SJS) SJS typically presents with skin and mucous membrane involvement, such as a skin rash, blistering, and mucosal lesions. Hyperreflexia is more commonly associated with neurological conditions, and it is not a typical symptom of SJS.
Choice B rationale:
Tinnitus with ear pain is not a characteristic manifestation of Stevens-Johnson syndrome (SJS) SJS primarily affects the skin and mucous membranes and does not typically involve the ears or auditory system. Tinnitus with ear pain could be related to other ear or auditory issues but is not associated with SJS.
Choice C rationale:
Diplopia (double vision) is not a typical manifestation of Stevens-Johnson syndrome (SJS) SJS primarily presents with skin and mucous membrane symptoms, including a rash, blisters, and mucosal lesions. Diplopia is more commonly associated with eye conditions or neurological disorders and is not a direct symptom of SJS.
Choice D rationale:
Skin rash with fever is a crucial manifestation to monitor and report in a client taking allopurinol because it can be indicative of Stevens-Johnson syndrome (SJS) Allopurinol is known to be associated with severe skin reactions like SJS, which can initially present as a skin rash with fever. Early recognition and reporting of this symptom are essential to prevent further complications. SJS is a medical emergency that requires immediate intervention.
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