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 client should not eat a light meal before an abdominal ultrasound because it can interfere with the quality of the images.
The client should fast for 8 to 12 hours before the procedure.
Some additional information about the other choices are:
Choice A is correct.
The client should drink plenty of fluids before an appointment for an abdominal ultrasound because it helps to fill the bladder and push the uterus up for better visualization.
Choice C is correct.
The client should wear comfortable clothing that can be easily removed or lifted up to expose the abdomen.
Choice D is correct.
The client should arrive at the appointment with a full bladder because it acts as an acoustic window and improves the quality of the ultrasound images.
Normal ranges for fetal growth and development during pregnancy vary depending on the gestational age, but some general parameters are:
Fetal heart rate: 110 to 160 beats per minute
Biparietal diameter: 2.4 to 9.5 cm
Crown-rump length: 0.8 to 8.4 cm
Femur length: 1.0 to 7.8 cm
Abdominal circumference: 9.4 to 35.6 cm
Correct Answer is A
Explanation
A Doppler ultrasound blood flow analysis measures the velocity of blood flow in the uterine and fetal vessels.
This test can help assess the fetal well-being and oxygenation in cases of intrauterine growth restriction (IUGR).
Choice B is wrong because the amount of amniotic fluid in the uterine cavity is measured by ultrasound, not Doppler.
Choice C is wrong because the pressure of blood flow in the umbilical cord is not directly measured by Doppler, but rather inferred from the resistance index or pulsatility index.
Choice D is wrong because the oxygen saturation level of fetal blood is not measured by Doppler, but rather by fetal scalp sampling or pulse oximetry.
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