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.
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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Related Questions
Correct Answer is A
Explanation
A. Repeat the complete prescription back to the provider – This is the correct action to ensure accuracy and prevent medication errors. The nurse must read back the prescription, including the medication name, dosage, route, and frequency, for verification.
B. Have a provider who is on site sign the prescription – The prescribing provider must sign the order within a specific timeframe, but this step occurs after verifying and documenting the prescription.
C. Have the unit secretary enter the prescription on the provider's order form – Only licensed personnel (nurses, pharmacists, or providers) can transcribe and verify medication orders. The unit secretary cannot enter prescriptions.
D. Verify the accuracy of the prescription with the pharmacist – The nurse should first confirm the order with the provider, not the pharmacist. The pharmacist’s role comes after the order is documented and entered.
Correct Answer is A
Explanation
A. A child who has acute epiglottitis and is drooling – This is the priority because drooling, stridor, and respiratory distress suggest airway obstruction, which is life-threatening. Immediate intervention is required to secure the airway.
B. A child who has a urinary tract infection and bright red blood in her urine – Hematuria can be concerning but is not immediately life-threatening.
C. A child who has mononucleosis and reports severe fatigue – Fatigue is common with mononucleosis but does not require immediate intervention.
D. A child who has Wilms' tumor and an abdominal mass – While Wilms' tumor is serious, it does not present an immediate airway or hemodynamic emergency.
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