A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?

Irrigate the insertion site with sterile water before the procedure.

Administer Rh.(D) immune globulin after the procedure.

Position the client in a left lateral position during the procedure

Inform the client to be NPO for the procedure.

Answer and Explanation

The Correct Answer is B

A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.

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Correct Answer is C

Explanation

A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.

A. The newborn's cord stump is still attached after 1 week. B. The newborn sleeps 16 hr a day. C. The newborn has fewer than four wet diapers in 24 hr D. The newborn has loose stools.

Correct Answer is C

Explanation

A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.

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A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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