A client at 20 weeks gestation reports discomfort after amniocentesis procedure to the nurse. Which of the following assessment findings warrants priority action by the nurse?
Braxton Hicks contraction
Amniotic fluid contains fetal urine
Prolonged vaginal bleeding
Lab results reveal abnormal chromosome cells
The Correct Answer is C
Explanation:
A. Braxton Hicks contraction
Braxton Hicks contractions are often referred to as "practice" contractions and are common during pregnancy. They are typically irregular and do not cause cervical changes. While discomfort after an amniocentesis procedure can sometimes trigger Braxton Hicks contractions, they are not usually a cause for immediate concern unless they become frequent, intense, or are accompanied by other signs of preterm labor, such as regular contractions, lower back pain, pelvic pressure, or changes in vaginal discharge.
B. Amniotic fluid contains fetal urine
The presence of fetal urine in the amniotic fluid is a normal and expected process during pregnancy. Fetal urine production contributes to the volume and composition of amniotic fluid, helping maintain the environment in the uterus and supporting fetal development. This finding is not directly related to the client's discomfort after an amniocentesis procedure and is not a cause for immediate concern unless there are other complications or abnormalities related to the amniotic fluid composition.
C. Prolonged vaginal bleeding
Prolonged vaginal bleeding after an amniocentesis procedure is a significant finding that requires immediate attention. While some spotting or mild bleeding can occur after the procedure, prolonged or significant bleeding may indicate complications such as uterine injury, placental abruption, or other issues that need urgent assessment and intervention by healthcare providers.
D. Lab results reveal abnormal chromosome cells
Abnormal chromosome cells found in the amniotic fluid sample obtained during amniocentesis may indicate genetic abnormalities or conditions in the fetus. While this finding is significant and requires follow-up and further evaluation, it is not an immediate concern in terms of the client's discomfort or the need for priority action by the nurse unless it is associated with other urgent clinical signs or symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A. Report of headache
Severe preeclampsia is characterized by hypertension (high blood pressure) along with other signs and symptoms of preeclampsia, such as proteinuria (protein in the urine) and end-organ dysfunction. Headache is a common symptom associated with severe preeclampsia and is often described as persistent and severe.
B. Polyuria
Polyuria, or excessive urination, is not typically associated with severe preeclampsia. In fact, decreased urine output (oliguria) can be a concern in severe cases due to reduced kidney function and fluid retention.
C. Tachycardia
Tachycardia, or a rapid heart rate, is not a typical finding in severe preeclampsia. In fact, hypertension and vascular constriction associated with preeclampsia can lead to normal or even lower heart rates in some cases.
D. Absence of clonus
Clonus refers to rhythmic, involuntary muscle contractions and relaxations. In the context of preeclampsia, the presence of clonus (especially hyperreflexia and positive clonus) is a concerning sign associated with central nervous system irritability and potential seizures. Absence of clonus would not be an expected finding in severe preeclampsia, as neurological manifestations such as hyperreflexia and clonus can occur in more severe cases.
Correct Answer is C
Explanation
Explanation:
A. "A gain of about 1 pound per week is the best pattern for you."
This response suggests a weight gain pattern rather than a total recommended weight gain for the entire pregnancy. A gain of about 1 pound per week would typically align with the recommended weight gain for individuals with a normal pre-pregnancy BMI (Body Mass Index). However, for someone with an overweight BMI (BMI 25 to 29.9), this rate of weight gain might be higher than the recommended range. Therefore, it may not be the best pattern for the client with a BMI of 26.5.
B. "It would be best if you gained about 11 to 20 pounds."
This response provides a weight gain range that is more appropriate for individuals with an obese BMI (BMI 30 or higher) rather than those with an overweight BMI. The recommended weight gain for someone with an overweight BMI is higher than 11 to 20 pounds. Therefore, this response underestimates the recommended weight gain for the client with a BMI of 26.5.
C. "The recommendation for you is about 15 to 25 pounds."
This response aligns with the recommended weight gain range for individuals with an overweight BMI (BMI 25 to 29.9). According to the Institute of Medicine (IOM) guidelines, the recommended weight gain for someone with an overweight BMI is about 15 to 25 pounds during pregnancy. This choice accurately reflects the appropriate recommendation for the client with a BMI of 26.5.
D. "A gain of about 25 to 35 pounds is recommended for you."
This response suggests a weight gain range that is more appropriate for individuals with a normal pre-pregnancy BMI (BMI 18.5 to 24.9). The recommended weight gain for someone with an overweight BMI is lower than 25 to 35 pounds. Therefore, this response overestimates the recommended weight gain for the client with a BMI of 26.5.
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