A nurse is caring for a patient who is at 15 weeks gestation, is rh-negative, and just had an Amniocentesis.
Which of the following interventions is the nurse’s priority following the procedure?
Check Pt.'s temp.
Observe for UC’s.
Administer Rho-Immunoglobulin.
Monitor the FHR.
The Correct Answer is C
Administer Rho-Immunoglobulin. This is because the patient is Rh-negative and has a risk of developing antibodies against the Rh antigen of the fetus, which can cause hemolytic disease of the fetus and newborn (HDFN) in subsequent pregnancies. Rho-Immunoglobulin prevents the maternal immune system from recognizing the fetal Rh antigen and producing antibodies.
Choice A is wrong because checking the patient’s temperature is not the priority intervention following an amniocentesis.
Temperature may be monitored to detect infection, but this is not as urgent as preventing Rh sensitization.
Choice B is wrong because observing for uterine contractions (UCs) is not the priority intervention following an amniocentesis.
UCs may indicate preterm labor, but this is not as common or as serious as HDFN.
Choice D is wrong because monitoring the fetal heart rate (FHR) is not the priority intervention following an amniocentesis.
FHR may be checked to assess fetal well-being, but this is not as important as preventing Rh sensitization.
Normal ranges:
• Temperature: 36.5°C to 37.2°C
• FHR: 110 to 160 beats per minute
• Anti-D antibody titer: < 1:8
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Related Questions
Correct Answer is C
Explanation
“You will need to have someone drive you home after the procedure.” Amniocentesis is a procedure in which your doctor removes a small amount of amniotic fluid from your uterus for testing or treatment.The procedure can cause some cramping, bleeding, or leaking of fluid, so you should rest and avoid strenuous activities for the rest of the day.
Having someone drive you home is a safety precaution.
Choice A is wrong because you will need to have anemptybladder for the procedure.This reduces the risk of puncturing the bladder with the needle and makes it easier to see the uterus on ultrasound.
Choice B is wrong because you will need to lie on yoursidefor the procedure.This prevents putting pressure on a major blood vessel called the vena cava, which can reduce blood flow to your baby.
Choice D is wrong because you willnotneed to avoid eating or drinking before the procedure.There is no evidence that fasting reduces the risk of complications from amniocentesis.
Correct Answer is B
Explanation
Monitor fetal heart rate.This is because cramping and vaginal bleeding after amniocentesis are signs of possible complications such as miscarriage, infection, or injury to the fetus.
Monitoring the 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) immune globulin 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 action to be taken.
While maternal vital signs can indicate infection or bleeding, they are less important than the fetal heart rate in this situation.
Choice D is wrong because obtaining an order for an ultrasound exam is not the first action to be taken.
While an ultrasound exam can help evaluate the amount of amniotic fluid and the position of the placenta and the fetus, it is not as urgent as monitoring the fetal heart rate.An ultrasound exam may be done later if there are concerns about the fetal condition or the amniotic fluid level.
Normal ranges for fetal heart rate are 110 to 160 beats per minute.Normal ranges for amniotic fluid index are 5 to 25 cm.Normal ranges for maternal vital signs vary depending on the stage of pregnancy, but generally they are: blood pressure 110/70 to 140/90 mmHg, pulse 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, and temperature 36.5 to 37.5°C.
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