A nurse is caring for a client who had an amniocentesis at 16 weeks gestation and reports cramping and vaginal bleeding 24 hours later.
Which of the following actions should the nurse take first?
Administer Rho(D) immune globulin.
Monitor fetal heart rate
Assess maternal vital signs
Obtain an order for an ultrasound exam.
The Correct Answer is B
The correct answer is choice B. Monitor fetal heart rate.
This is because cramping and vaginal bleeding after amniocentesis are signs of possible complications such as miscarriage, preterm labor, or injury to the fetus.
Monitoring fetal heart rate can help assess the well-being of the fetus and detect any signs of distress.
Choice A is wrong because administering Rho(D) immunoglobulin is only necessary if the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause Rh sensitization.
This is not given routinely to all women who have amniocentesis.
Choice C is wrong because assessing maternal vital signs is not the first priority when there is a risk of fetal compromise.
Maternal vital signs can be affected by many factors and are not specific indicators of fetal health.
Choice D is wrong because obtaining an order for an ultrasound exam is not the first action to take.
An ultrasound exam can help confirm the diagnosis of complications such as placental abruption or fetal demise, but it requires time and equipment that might delay immediate intervention.
Monitoring fetal heart rate can be done quickly and easily at the bedside.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An equivocal CST indicates late decelerations of the FHR with less than 50% of contractions.
This means that the fetus may have some degree of hypoxia or distress, but not enough to warrant immediate delivery.
An equivocal CST may also result from hyperstimulation of the uterus, which can cause excessive contractions and reduce blood flow to the placenta.
Choice B is wrong because late decelerations of the FHR with at least 50% of contractions is a positive CST, which indicates a high risk of fetal death due to hypoxia and is a contraindication to labor.
Choice C is wrong because no late decelerations of the FHR during contractions is a negative CST, which indicates a good fetal wellbeing and tolerance of labor.
Choice D is wrong because variable decelerations of the FHR with or without contractions are not related to uterine activity and may indicate cord compression or other fetal problems.
Variable decelerations are not used to interpret CST results.
Correct Answer is C
Explanation
According to the ACOG guidelines on antepartum fetal surveillance, one of the components of the biophysical profile is fetal breathing movements, which are scored as 2 points if there is one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes.
Choice A is wrong because 0 points are given for absent or no breathing episode for ≥30 seconds within a 30 minute observation period.
Choice B is wrong because there is no 1 point score for this variable.
Choice D is wrong because there is no 3 point score for this variable.
The maximum score for each variable is 2 points.
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