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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Each of the five variables in a biophysical profile (BPP) is assigned a score of either 0 or 2 points, depending on whether it meets the criteria or not.

The five variables are:

Fetal breathing: 2 points if there is at least one episode of rhythmic breathing lasting at least 30 seconds within 30 minutes, 0 points otherwise.

Fetal movement: 2 points if there are at least three discrete body or limb movements within 30 minutes, 0 points otherwise.

Fetal tone: 2 points if there is at least one episode of extremity extension and subsequent return to flexion, 0 points otherwise.

Amniotic fluid volume: 2 points if there is a pocket of amniotic fluid measuring at least 2 cm in two perpendicular planes, 0 points otherwise.

Nonstress test: 2 points if there are at least two accelerations of fetal heart rate with or without fetal movement within 20 minutes, 0 points otherwise.

Choice A is wrong because each variable can have a score of either 0 or 2, not 0 or.

Choice C is wrong because there is no score of 1 for any variable.

Choice D is wrong because it is incomplete and does not provide the full range of possible scores.

A. Administer Rho(D) immune globulin. B. Monitor fetal heart rate C. Assess maternal vital signs D. Obtain an order for an ultrasound exam

Correct Answer is B

Explanation

This is because cramping and vaginal bleeding after an amniocentesis may indicate a possible miscarriage or placental abruption, which can compromise fetal oxygenation and perfusion.

Monitoring fetal heart rate can help detect signs of fetal distress and guide further interventions.

Choice A is wrong because administering Rho(D) immune globulin is indicated for Rh-negative mothers who undergo amniocentesis to prevent isoimmunization, but it is not a priority action in this scenario.

Choice C is wrong because assessing maternal vital signs is important to monitor for signs of infection, hemorrhage, or shock, but it is not as urgent as monitoring fetal well-being.

Choice D is wrong because obtaining an order for an ultrasound exam can help confirm the diagnosis and evaluate the placenta and amniotic fluid, but it is not the first action to take in this situation.

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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?

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Naxlex Comprehensive Predictor Exams

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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?