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 B
Explanation
This test can detect genetic disorders.
Chorionic villus sampling (CVS) is a prenatal test that involves taking a sample of tissue from the placenta to test for chromosomal abnormalities and certain other genetic problems.
The placenta is a structure in the uterus that provides blood and nutrients from the mother to the fetus.
Choice A is wrong because CVS does not provide information on neural tube defects, such as spina bifida.
For this reason, women who undergo CVS also need a follow-up blood test between 16 to 18 weeks of their pregnancy to screen for neural tube defects.
Choice C is wrong because CVS can detect chromosomal abnormalities, but not all chromosomal abnormalities are genetic disorders.
For example, Down syndrome is a chromosomal abnormality caused by an extra copy of chromosome 21, but it is not inherited from the parents.
Choice D is wrong because CVS cannot detect Rh sensitization, which is a condition where the mother’s immune system produces antibodies against the fetus’s blood type.
Rh sensitization can be detected by a blood test that measures the level of antibodies in the mother’s blood.
Correct Answer is A
Explanation
The baby’s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy.
This is a device that uses sound waves to create an image of the baby’s heart and measure its rate and rhythm.
Some possible explanations for the other choices are:
Choice B is wrong because the baby’s sex can not be determined by ultrasound at 8 weeks of pregnancy.
The external genitalia are not fully developed until around 14 to 16 weeks of pregnancy.
Even then, the accuracy of ultrasound depends on factors such as the position of the baby, the quality of the equipment, and the skill of the sonographer.
Choice C is wrong because the baby’s lungs are not fully mature by 24 weeks of pregnancy.
The lungs are one of the last organs to develop in the fetus and they continue to grow and mature until near term.
The production of surfactant, a substance that helps the lungs expand and prevent collapse, begins around 24 weeks but is not sufficient until around 34 to 36 weeks.
Choice D is wrong because the baby’s eyes do not open and close by 16 weeks of pregnancy.
The eyelids are fused together until around 26 to 28 weeks of pregnancy, when they start to open and close periodically.
The baby can also respond to light and dark stimuli around this time.
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