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
The correct answer is choice B. The nurse should inform her that results are typically available within 7 days.
This is known as the rapid CVS result.
A more detailed set of CVS results will be available within 2 weeks.
Choice A is wrong because 24 hours is too short for the laboratory to test the sample of cells from the placenta.
Choice C is wrong because 10-14 days is the timeframe for the more detailed set of CVS results, not the rapid CVS result.
Choice D is wrong because 30 days is too long for the results to be available.
The woman would need to know the results sooner to make informed decisions about her pregnancy.
Correct Answer is A
Explanation
An NST is a test that measures the fetal heart rate in response to fetal movement.
It is a non-invasive and simple way to assess fetal well-being.
An NST may be recommended to further evaluate fetal well-being if the CST result is equivocal, meaning that occasional but not persistent late decelerations are present.
Choice B. Amniocentesis is wrong because it is an invasive procedure that involves inserting a needle into the uterus to collect amniotic fluid for genetic testing or fetal lung maturity.
It is not used to evaluate fetal well-being in response to contractions.
Choice C. Magnetic resonance imaging (MRI) is wrong because it is an imaging technique that uses magnetic fields to create detailed pictures of the fetus and the placenta.
It is not used to evaluate fetal well-being in response to contractions.
Choice D. Chorionic villus sampling (CVS) is wrong because it is an invasive procedure that involves inserting a catheter or a needle into the placenta to collect chorionic villi for genetic testing.
It is not used to evaluate fetal well-being in response to contractions.
Normal ranges for CST are negative (normal) or positive (abnormal).
Equivocal and unsatisfactory are special categories of test outcomes that require further testing.
Normal ranges for NST are reactive (reassuring) ornon-reactive (non-reassuring).
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