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 C
Explanation
The level of AFP in a pregnant woman’s blood depends on how far along she is in her pregnancy.
AFP levels are normally high in the early weeks of pregnancy and then decline as the pregnancy progresses.
If the AFP level is too high or too low for the gestational age, it may indicate a problem with the baby’s development.
Choice A is wrong because maternal weight does not affect AFP levels.
Choice B is wrong because fetal heart rate does not affect AFP levels.
Choice D is wrong because the placental function does not affect AFP levels directly, but it may affect the levels of other hormones that are measured along with AFP in a quad screen.
Correct Answer is A
Explanation
“I will have sensors placed on my abdomen to monitor the FHR and uterine contractions.” This statement indicates the client understands the test procedure of a CST, which is a test that triggers contractions and registers how the baby’s heart reacts.
The test is done by placing two sensor belts around the abdomen, one to measure the baby’s heartbeat and the other to measure contractions.
The client may receive oxytocin through an IV to induce contractions.
Choice B is wrong because the client does not need to fast for 24 hours before the test.
There is no evidence that fasting is required for a CST.
Choice C is wrong because the client will not be sedated during the test.
Sedation is not necessary for a CST and may interfere with the results.
Choice D is wrong because the client does not need to drink plenty of fluids before the test.
There is no evidence that drinking fluids is required for a CST.
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