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 D

Explanation

A. Influenza – The first dose of the influenza vaccine is recommended at 6 months, not 2 months.

B. Hepatitis A – Hepatitis A vaccine is typically given at 12-23 months, not at 2 months.

C. Varicella – The varicella (chickenpox) vaccine is given at 12-15 months, so it is not appropriate for a 2-month-old.

D. Rotavirus – This is the correct answer. The rotavirus vaccine is recommended at 2 months, 4 months, and possibly 6 months, depending on the vaccine brand used.

A. Tachycardia B. Hearing loss C. Insomnia D. Blurred vision

Correct Answer is D

Explanation

A. Tachycardia – Digoxin toxicity typically causes bradycardia, not tachycardia, due to its effect on the AV node.

B. Hearing loss – Digoxin does not commonly cause hearing loss; ototoxicity is more associated with aminoglycoside antibiotics.

C. Insomnia – While some neurological symptoms may occur, insomnia is not a classic sign of digoxin toxicity.

D. Blurred vision – This is the correct answer. Digoxin toxicity can cause visual disturbances such as blurred vision, yellow-green halos, and scotomas. Other signs include nausea, vomiting, anorexia, fatigue, and cardiac arrhythmias.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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