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

Answer and Explanation

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.

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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.

A. "I should drink about 2 liters of fluid each day." B. "I can have a moderate amount of caffeine daily." C. "I should not drink alcoholic beverages during my pregnancy." D. "I should increase my calcium intake to 1,500 milligrams per day."

Correct Answer is D

Explanation

Explanation:

A. "I should drink about 2 liters of fluid each day."

This statement is generally accurate and aligned with recommendations for adequate hydration during pregnancy. The recommended daily fluid intake for pregnant individuals is typically around 8 to 10 cups of fluids per day, which is approximately 2 liters. Adequate hydration is important during pregnancy to support overall health, prevent dehydration, and maintain proper functioning of bodily systems.

B. "I can have a moderate amount of caffeine daily."

This statement is generally acceptable and aligned with guidelines from organizations such as the American College of Obstetricians and Gynecologists (ACOG). Moderate caffeine intake, typically defined as up to 200 milligrams per day, is considered safe during pregnancy for most individuals. However, it's essential to be mindful of caffeine sources and consume them in moderation, as excessive caffeine intake can have adverse effects on pregnancy outcomes.

C. "I should not drink alcoholic beverages during my pregnancy."

This statement is correct and crucial for a healthy pregnancy. Alcohol consumption during pregnancy is associated with various risks, including fetal alcohol spectrum disorders (FASDs) and developmental issues. Therefore, healthcare providers universally recommend abstaining from alcohol entirely during pregnancy to protect the health and well-being of both the mother and the developing baby.

D. "I should increase my calcium intake to 1,500 milligrams per day."

This statement indicates a need for clarification because the recommended daily intake of calcium during pregnancy is typically around 1,000 milligrams per day for most pregnant individuals. While some healthcare providers may recommend slightly higher amounts, such as up to 1,300 milligrams per day, a calcium intake of 1,500 milligrams per day is relatively high and may not align with standard recommendations without specific indications such as a history of low calcium levels or certain medical conditions. It's important for the nurse to clarify and provide accurate information regarding appropriate calcium intake during pregnancy based on the client's individual needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is D

Explanation

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

Correct Answer is D

Explanation

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