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.

Answer and Explanation

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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Correct Answer is A

Explanation

- A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.

- B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.

- C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.

- D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.

A. Alternate eating solid foods and liquids B. Eat every 2 to 3 hr C. Drink warm ginger ale when nauseated D. Increase intake of high-fat foods E. Recommended actions

Correct Answer is ["A","B","C","E"]

Explanation

Correct answer: A, B, C, E

Rationale:

A: Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
B: Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
C: Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
E: Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
D: Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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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?