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","C","D","E"]
Explanation
Explanation:
A. Hypotension: Spinal cord injuries, especially cervical injuries, can affect autonomic nervous system function, leading to neurogenic shock and hypotension. The disruption of sympathetic nervous system control over blood vessels can result in vasodilation and a drop in blood pressure.
B. Polyuria: While urinary dysfunction is a common complication of spinal cord injuries, especially with higher-level injuries, polyuria (excessive urine production) is more commonly associated with lower-level spinal cord injuries affecting the sacral segments. Cervical spinal cord injuries are more likely to lead to neurogenic bladder, urinary retention, or incontinence rather than polyuria.
C. Absence of bowel sounds: Spinal cord injuries can affect the gastrointestinal system, leading to a decrease or absence of bowel sounds due to impaired bowel motility. This can result in paralytic ileus or constipation.
D. Weakened gag reflex: Spinal cord injuries involving the cervical region can affect the pharyngeal and laryngeal nerves, leading to a weakened gag reflex. This can increase the risk of aspiration and difficulty swallowing.
E. Hyperthermia: Spinal cord injuries can disrupt thermoregulation, leading to difficulties in temperature control. Clients with cervical spinal cord injuries may be at risk of hyperthermia due to impaired sweating and heat dissipation mechanisms.
Correct Answer is D
Explanation
Explanation:
A. Bowel sounds
While assessing bowel sounds is important in general nursing care, it is not the priority assessment when administering magnesium sulfate IV to a client in preterm labor. Bowel sounds can provide information about gastrointestinal function and potential complications like bowel obstruction or ileus. However, these assessments are not directly related to the immediate effects of magnesium sulfate on the client or fetus during preterm labor.
B. Temperature
Monitoring temperature is important to detect signs of infection, which could be a concern in any patient receiving IV medications. However, it is not the priority assessment when administering magnesium sulfate IV for preterm labor. The primary concern with magnesium sulfate is its effect on neuromuscular function and its potential impact on the fetus, making fetal heart rate monitoring a higher priority.
C. Respiratory rate
Assessing respiratory rate is crucial for monitoring respiratory status and detecting signs of respiratory distress or magnesium toxicity, which can affect respiratory function. While respiratory rate is an essential assessment, it is not the priority when administering magnesium sulfate IV for preterm labor. Fetal heart rate monitoring takes precedence due to the direct impact of magnesium sulfate on uterine contractions and fetal well-being.
D. Fetal heart rate (FHR)
Fetal heart rate monitoring is the priority nursing assessment when preparing to administer magnesium sulfate IV to a client experiencing preterm labor. Magnesium sulfate can affect fetal heart rate and overall fetal well-being, so continuous fetal heart rate monitoring allows the nurse to assess the baby's response to the medication and detect any adverse effects promptly. Monitoring FHR helps ensure the safety and well-being of the fetus during magnesium sulfate therapy.
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