A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

Place the client in Trendelenburg position during the procedure.

Instruct the client to maintain a full bladder for the procedure.

Administer a tocolytic 30 min before the procedure.

Monitor the fetal heart rate throughout the procedure.

Answer and Explanation

The Correct Answer is D

A. Place the client in Trendelenburg position during the procedure – Incorrect, as amniocentesis is typically performed with the client in a supine position.

B. Instruct the client to maintain a full bladder for the procedure – This is required for an early pregnancy amniocentesis (before 20 weeks), but for later procedures, the bladder should be empty.

C. Administer a tocolytic 30 min before the procedure – Not routinely necessary unless the client is at risk for preterm labor.

D. Monitor the fetal heart rate throughout the procedure – Correct, as amniocentesis carries a risk of fetal distress, and continuous monitoring ensures immediate detection of complications.

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Correct Answer is C

Explanation

A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.

B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.

C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.

D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.

A. Heart rate 148/min B. Potassium 3.9 mEq/L C. Respiratory rate 22/min D. Sodium 142 mEq/L

Correct Answer is A

Explanation

A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.

B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).

C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.

D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).

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A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

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