A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis.
The client asks why she is having an ultrasound prior to the procedure.
Which of the following responses by the nurse is appropriate?
"This is a screening tool for spina bifida.”.
"It is useful for estimating fetal age.”.
"It assists in identifying the location of the placenta and fetus.”.
"This will determine if there is more than one fetus.”. .
The Correct Answer is C
Choice A rationale:
"This is a screening tool for spina bifida.”. This statement is incorrect. An ultrasound performed before an amniocentesis is not primarily used as a screening tool for spina bifida. Spina bifida can be detected through other diagnostic tests.
Choice B rationale:
"It is useful for estimating fetal age.”. While ultrasounds can provide information about fetal age, it is not the primary reason for performing an ultrasound before an amniocentesis. The main purpose is to identify the location of the placenta and fetus, which is essential for safely performing the amniocentesis procedure.
Choice C rationale:
"It assists in identifying the location of the placenta and fetus.”. This is the correct answer. An ultrasound before amniocentesis is crucial for locating the fetus and the placenta accurately. This information helps healthcare providers ensure the safe and precise insertion of the needle into the amniotic sac.
Choice D rationale:
"This will determine if there is more than one fetus.”. Determining if there is more than one fetus is an important aspect of prenatal care but is not the primary reason for performing an ultrasound before amniocentesis. It is generally confirmed through earlier ultrasounds during routine prenatal care. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Tell me more about your concerns" is an appropriate therapeutic response by the nurse. It encourages the client to express her worries and fears about the pelvic examination. Open-ended questions like this one allow the nurse to better understand the client's specific concerns, which can help in addressing them effectively.
Choice B rationale:
"All you need to do is relax during the exam" may come across as dismissive and may not address the client's anxiety effectively. It's important to acknowledge the client's feelings and offer support rather than making the situation seem overly simplistic.
Choice C rationale:
"Don't worry. I will stay in there with you for the exam" might make the client feel like she has no control over the situation and can be invasive. While offering support is important, it's essential to respect the client's autonomy and provide emotional support through active listening and communication.
Choice D rationale:
"A pelvic exam is required if you want birth control pills" is not an appropriate response to the client's anxiety about the pelvic exam. This response does not address the client's concerns and may not provide the necessary emotional support or information she needs.
Correct Answer is B
Explanation
To calculate the estimated date of delivery (EDD) using Naegele’s rule, the nurse would:
- Add one year to the year of the last menstrual period (LMP).
- Subtract three months from the month of the LMP.
- Add seven days to the day of the LMP.
Given the first day of the client’s last menstrual period was April 4, 2023:
- Adding one year: April 4, 2024
- Subtracting three months: January 4, 2024
- Adding seven days: January 11, 2024
So, the nurse should tell the client that her estimated date of delivery (EDD) isJanuary 11, 2024.
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