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
An amniotic fluid index (AFI) of 4 cm indicates oligohydramnios, which is a low amount of amniotic fluid.
Oligohydramnios can be caused by various factors, such as uteroplacental insufficiency, rupture of membranes, postterm pregnancy, fetal anomalies, or certain medications.
Oligohydramnios can lead to complications such as fetal death, intrauterine growth restriction, limb contractures, or delayed lung maturation.
Choice A is wrong because an AFI of 8 cm is within the normal range for amniotic fluid volume.
Choice C is wrong because a single vertical pocket of amniotic fluid measuring 3 cm is also within the normal range for amniotic fluid volume.
Choice D is wrong because a single vertical pocket of amniotic fluid measuring 5 cm is also within the normal range for amniotic fluid volume.
Normal ranges for AFI and single vertical pocket are > 5 to < 24 cm and ≥ 2 to < 8 cm, respectively.
Correct Answer is A
Explanation
An alpha-fetoprotein test (AFP) is a blood test that measures the amount of AFP present in blood.
It’s usually part of what’s called a triple screen or quad screen in the second trimester of pregnancy.
The yolk sac, GI tract, and liver of an unborn baby produce AFP.
It then circulates through the fetal and maternal blood.
High levels of AFP in pregnant people can indicate that the baby has a neural tube defect, such as spina bifida or anencephaly.
Choice B is wrong because assessing placental function is not the primary purpose of an AFP test.
However, low levels of AFP can indicate problems with the placenta or the baby’s growth.
Choice C is wrong because determining fetal gender is not the primary purpose of an AFP test.
However, some genetic tests that use a sample of the baby’s DNA from the pregnant person’s blood can reveal the baby’s sex as early as 10 weeks of pregnancy.
Choice D is wrong because diagnosing chromosomal abnormalities is not the primary purpose of an AFP test.
However, an AFP test is usually part of a quad screen that also tests for other markers that can indicate the risk of chromosomal abnormalities, such as Down syndrome.
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