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?
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.
Place the client in Trendelenburg position during the procedure.
The Correct Answer is C
Choice A rationale:
Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.
Choice B rationale:
Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.
Choice C rationale:
Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.
Choice D rationale:
Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.
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Related Questions
Correct Answer is D
Explanation
Place the client in a quiet environment.
- A. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
- B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate.Therefore, this choice is incorrect.
- C. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
- D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.
Correct Answer is B
Explanation
Use a reward system to modify the child's behavior.
Rationale:
- A. Incorrect. Maintaining a flexible daily schedule for the child may increase their anxiety and confusion, as they may have difficulty adapting to changes in routine and expectations. The nurse should advise the parents to establish a consistent and structured schedule for the child, with clear rules and boundaries.
- B. Correct. Using a reward system to modify the child's behavior is an effective strategy to reinforce positive behaviors and reduce negative ones. The nurse should help the parents identify specific and measurable goals for the child, and provide them with praise, tokens, or privileges when they achieve them.
- C. Incorrect. Providing a variety of family members to care for the child may overwhelm them and impair their social skills development, as they may have difficulty forming attachments and communicating with different people. The nurse should encourage the parents to select one or two primary caregivers for the child, who can provide them with consistent and supportive interactions.
- D. Incorrect. Administering alprazolam as needed to reduce the child's anxiety is not recommended, as it may cause adverse effects such as sedation, dependence, or withdrawal symptoms. The nurse should educate the parents about nonpharmacological interventions for anxiety, such as relaxation techniques, cognitive behavioral therapy, or social skills training.
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