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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client has a history of bleeding disorders.
This is because amniocentesis is an invasive procedure that involves passing a needle through the abdomen and into the uterus to collect a sample of amniotic fluid.This can cause bleeding and increase the risk of miscarriage.
A client with a bleeding disorder may have difficulty clotting and may experience excessive bleeding after the procedure.
Choice A is wrong because asthma is not a contraindication for amniocentesis.
Asthma is a chronic lung condition that causes inflammation and narrowing of the airways.
It does not affect the ability to perform amniocentesis or the risk of complications.
Choice B is wrong because diabetes is not a contraindication for amniocentesis.
Diabetes is a condition that affects how the body uses glucose, a type of sugar that is the main source of energy for cells.
It does not affect the ability to perform amniocentesis or the risk of complications.
Choice D is wrong because hypertension is not a contraindication for amniocentesis.
Hypertension is a condition that causes high blood pressure, which can damage the heart and blood vessels.
It does not affect the ability to perform amniocentesis or the risk of complications.
Normal ranges for blood pressure are less than 120/80 mmHg, for blood glucose are 70-130 mg/dL before meals and less than 180 mg/dL after meals, and for clotting time are 8-15 minutes.
Correct Answer is C
Explanation
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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