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 A

Explanation

Explanation:

A. An excessive amount of amniotic fluid is present.

Polyhydramnios is defined as an excessive accumulation of amniotic fluid within the amniotic sac surrounding the fetus. This condition can occur due to various factors, including fetal abnormalities, maternal health conditions such as diabetes or gestational diabetes, multiple gestations (twins, triplets, etc.), or idiopathic causes where no specific underlying condition is identified. The increased volume of amniotic fluid can be detected through ultrasound examinations, where amniotic fluid index (AFI) measurements are taken to assess the quantity of fluid present. Polyhydramnios is typically diagnosed when the AFI exceeds a certain threshold.

B. The client is carrying more than one fetus.

While it's true that multiple gestations, such as twins or triplets, can sometimes lead to polyhydramnios, the presence of polyhydramnios does not automatically indicate a multiple pregnancy. Polyhydramnios can occur in singleton pregnancies as well, particularly due to other factors like fetal anomalies, maternal health issues, or idiopathic reasons.

C. The fetus is likely to have a congenital anomaly, be growth-restricted, or demonstrate fetal distress during labor.

Polyhydramnios can be associated with various fetal and maternal conditions, but it does not directly indicate specific fetal issues like congenital anomalies, growth restriction, or fetal distress during labor. However, polyhydramnios can sometimes coexist with these conditions or be a result of them. For example, certain fetal abnormalities, such as gastrointestinal obstructions, can lead to polyhydramnios due to impaired swallowing and absorption of amniotic fluid.

D. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid.

Elevated levels of alpha-fetoprotein (AFP) in the amniotic fluid are typically associated with neural tube defects (such as spina bifida) or abdominal wall defects (like gastroschisis or omphalocele) in the fetus. However, AFP levels are not directly related to the presence of polyhydramnios. AFP testing is usually done separately as part of prenatal screening tests to assess the risk of certain fetal abnormalities.

A. Report of headache B. Polyuria C. Tachycardia D. Absence of clonus

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.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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