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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Advocacy is a leadership role that helps others to self-actualize.
- A. Advocacy is a leadership role that helps others to self-actualize. This statement is true and reflects one of the core principles of advocacy, which is to empower others to achieve their full potential and exercise their rights and responsibilities. This choice is correct.
- B. Subordinates are advocates for the nurse manager. This statement is false and contradicts one of the core principles of advocacy, which is to act in the best interest of those who are vulnerable or oppressed, not those who are in positions of power or authority. This choice is incorrect.
- C. Advocacy encourages clients to rely on health care staff for decision-making. This statement is false and contradicts one of the core principles of advocacy, which is to respect and support clients' autonomy and self-determination, not to impose or influence their choices or actions. This choice is incorrect.
- D. Nurse managers should distrust people who expose inappropriate professional practices. This statement is false and contradicts one of the core principles of advocacy, which is to promote and uphold ethical standards and quality of care, not to conceal or ignore malpractice or misconduct. This choice is incorrect.
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