A nurse is caring for a client who is scheduled for an amniocentesis at 16 weeks gestation.
Which of the following should the nurse report to the provider?
The client’s bladder is full.
The client’s uterus is above the symphysis pubis
The client’s cervix is dilated
The client’s fundal height measures 20 cm
The Correct Answer is C
. The client’s cervix is dilated.
This indicates that the client may be in preterm labor, which is a contraindication for amniocentesis.
Amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for genetic testing or other purposes.
It is usually performed between 15 and 20 weeks of gestation.
Choice A is wrong because the client’s bladder should be full for amniocentesis.
This helps to push the uterus upward and away from the bladder, reducing the risk of injury and making it easier to visualize the fetus and the needle.
Choice B is wrong because the client’s uterus should be above the symphysis pubis at 16 weeks of gestation.
This is a normal finding and does not affect the procedure.
Choice D is wrong because the client’s fundal height should measure around 16 cm at 16 weeks of gestation.
A fundal height of 20 cm may indicate a large for gestational age fetus, multiple gestation, or polyhydramnios (excess amniotic fluid), but these are not absolute contraindications for amniocentesis.
However, they may require further evaluation and adjustment of the technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
This is because a nuchal translucency ultrasound measures the amount of fluid behind the baby’s neck in the first trimester of pregnancy, which can indicate the risk of having a chromosomal condition like Down syndrome.
Some possible explanations for the other choices are:
Choice A is wrong because fetal growth and development are not directly related to the nuchal translucency measurement.
Fetal growth and development are assessed by other parameters such as crown-rump length, biparietal diameter, abdominal circumference, etc.
Choice B is wrong because blood flow in the umbilical cord is not measured by the nuchal translucency ultrasound.
Blood flow in the umbilical cord is assessed by Doppler ultrasound, which evaluates the resistance and velocity of blood flow in the umbilical artery and vein.
Choice D is wrong because structural abnormalities in the baby’s organs are not detected by the nuchal translucency ultrasound.
Structural abnormalities in the baby’s organs are diagnosed by a detailed anatomy scan, which is usually performed in the second trimester of pregnancy.
The normal range for nuchal translucency is between 1 mm and 3 mm.
A measurement above 3 mm is considered increased and may indicate a higher risk of chromosomal or genetic conditions.
However, a nuchal translucency ultrasound is a screening test and not a diagnostic test, so it does not confirm or rule out any condition.
It only provides a probability based on statistical calculations.
Therefore, further testing may be recommended if the nuchal translucency measurement is increased or if other risk factors are present.
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