A nurse in a prenatal office is caring for a client who is at gestation and is scheduled for an amniocentesis.
The client asks why ultrasounds are performed prior to the procedure. Which of the following responses by the nurse is appropriate?
The ultrasound determines there is more than one fetus.
The ultrasound is for determining fetal age.
The ultrasound is for identifying the location and mass.
The ultrasound is for imaging.
The Correct Answer is C
Choice A:
While an ultrasound can indeed determine if there are multiple fetuses, this is not the primary reason for performing it prior to amniocentesis. The number of fetuses is typically established earlier in pregnancy through routine ultrasounds.
Focusing solely on multiple fetuses might lead the client to believe that ultrasounds are only conducted in such cases, which is not accurate.
Choice B:
Determining fetal age is a crucial aspect of prenatal care, but it's not the main reason for an ultrasound before amniocentesis. Fetal age is typically assessed through earlier ultrasounds, often in the first trimester.
Highlighting fetal age might misinform the client about the specific purpose of the ultrasound in this context.
Choice C:
This is the most appropriate response because it accurately identifies the primary purpose of the ultrasound.
Amniocentesis involves inserting a needle into the amniotic sac to collect a sample of amniotic fluid. To ensure the safety of the procedure and minimize risks to the fetus, it's essential to accurately visualize the location of the amniotic sac and placenta, as well as assess the position of the fetus.
Ultrasound provides real-time imaging that allows the healthcare provider to visualize these structures with precision, guiding the needle insertion and reducing the risk of complications.
Choice D:
While stating that the ultrasound is for imaging is technically correct, it's too general and doesn't provide the specific reason for its use in this context.
A more informative response would clarify the specific imaging goals for amniocentesis, as outlined in Choice C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Tachycardia, or a fast heart rate, is not a common finding in severe preeclampsia. While some women with preeclampsia may experience a slight increase in heart rate, it is not typically a significant or defining feature of the condition. In fact, some women with severe preeclampsia may even experience a slightly decreased heart rate due to increased vagal tone.
Choice B rationale:
Hypotension, or low blood pressure, is also not a typical finding in severe preeclampsia. Blood pressure is often elevated in preeclampsia, and it is one of the key diagnostic criteria. Hypotension would be a concerning finding in a woman with preeclampsia, as it could indicate a serious complication such as placental abruption or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).
Choice C rationale:
Polyuria, or excessive urination, is not a characteristic finding of severe preeclampsia. In fact, many women with preeclampsia experience oliguria, or decreased urine output, due to decreased kidney function. This is because preeclampsia can cause damage to the blood vessels in the kidneys, impairing their ability to filter blood and produce urine.
Choice D rationale:
Headache is a common and often severe symptom of severe preeclampsia. It is thought to be caused by increased pressure within the brain due to swelling and vasoconstriction of the blood vessels. Headaches in preeclampsia can be very intense and may be accompanied by other symptoms such as blurred vision, nausea, and vomiting. They are often a sign that the preeclampsia is worsening and that delivery may be necessary.
Correct Answer is C
Explanation
Choice A rationale:
A negative test implies a non-reactive NST, meaning the fetal heart rate (FHR) did not demonstrate the expected accelerations in response to fetal movements.
However, the scenario states that fetal movements were noted, and decelerations were observed. Decelerations, even lasting 30 seconds, are not consistent with a negative test.
Choice B rationale:
A positive test is not a standard term used in the context of NST results.
The term "positive" is more often associated with tests that identify a specific condition or abnormality.
NST results are typically classified as reactive or non-reactive, with further interpretation based on the presence or absence of decelerations and other FHR patterns.
Choice C rationale:
A reactive NST is the desired outcome, indicating a healthy fetal response to movement.
It requires two or more FHR accelerations of at least 15 beats per minute for a minimum of 15 seconds, each within a 20- minute period.
Although the decelerations lasting 30 seconds warrant further assessment, they do not negate the presence of the required accelerations, making the test reactive.
Choice D rationale:
"Non-reactive deceleration of rising in the fetal heart rate during a period" is not a standard NST result terminology.
It incorrectly combines elements of non-reactivity (lack of accelerations) with a description of decelerations, which are distinct FHR patterns.
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