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 B
Explanation
Explanation:
G - Gravida: The number of pregnancies, including the current one.
T - Term births: The number of pregnancies carried to term, typically considered 37 weeks or more.
P - Preterm births: The number of pregnancies delivered between 20 and 37 weeks.
A - Abortions: The number of pregnancies terminated before 20 weeks, including elective abortions and miscarriages.
L - Living children: The number of living children.
Now let's analyze the client's history:
Elective abortion at 9 weeks (terminated pregnancy): This counts as an abortion (A).
Birth of twins at 36 weeks (term births): This counts as two term births (T).
Spontaneous abortion at 15 weeks (miscarriage): This also counts as an abortion (A).
Based on the information provided, the client's GTPAL status would be:
Gravida: 4 (1 terminated pregnancy + 1 twin birth + 1 miscarriage + 1 current pregnancy)
Term births: 2 (1 twin birth)
Preterm births: 0
Abortions: 2 (1 terminated pregnancy + 1 miscarriage)
Living children: 2 (1 twin birth)
Correct Answer is D
Explanation
Explanation:
A. This test assesses fetal lung maturity.
The explanation provided is incorrect. The maternal serum alpha-fetoprotein (MSAFP) test is not used to assess fetal lung maturity. Fetal lung maturity is typically assessed through tests such as amniocentesis, which evaluates factors like the lecithin-to-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels in amniotic fluid.
B. This test identifies an Rh incompatibility between the mother and fetus.
The explanation provided is also incorrect. The MSAFP test is not used to identify Rh (Rhesus) incompatibility between the mother and fetus. Rh incompatibility is determined through other tests, such as blood typing (Rh factor) and antibody screening.
C. It assesses various markers of fetal well-being.
This explanation is not accurate. While the MSAFP test does provide information about certain fetal abnormalities, it is primarily used as a screening test for neural tube defects (spinal defects) and abdominal wall defects rather than assessing overall fetal well-being, which involves a comprehensive evaluation of various fetal parameters.
D. It is a screening test for spinal defects in the fetus.
This explanation is correct. The MSAFP test is indeed a screening test specifically used to assess the risk of spinal defects, also known as neural tube defects, in the fetus. These defects include conditions such as spina bifida. The test measures the levels of alpha-fetoprotein in the mother's blood to screen for these abnormalities during pregnancy.
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