A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Instruct the client to be NPO for six hours prior to the procedure

Instruct the client to maintain a full bladder for the procedure

Monitor the fetal heart rate prior to the procedure.

Place the client in Trendelenburg position during the procedure

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.

B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.

C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.

D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. "Have your child lie down and turn their head to the side for 10 minutes." Lying down increases blood flow to the head, which can worsen the nosebleed or cause aspiration if blood is swallowed. Upright posture is preferred to reduce venous pressure in nasal vessels.

B. "Place a warm, wet washcloth over your child's forehead and the bridge of their nose." Warm compresses can dilate blood vessels and worsen bleeding. Cold compresses are more appropriate to constrict blood vessels and reduce blood flow.

C. "Tell your child to blow their nose gently and then sit down and put their head backward." Blowing the nose can dislodge clots and worsen bleeding. Tilting the head back can cause blood to run down the throat, increasing the risk of nausea, vomiting, or aspiration.

D. "Use your thumb and forefinger to apply pressure to the sides of your child's nose."
Pinching the soft part of the nose for 10–15 minutes while the child leans slightly forward is the first-line intervention for epistaxis. This reduces bleeding and prevents aspiration.

A. Client presents for evaluation of severe pain in upper abdomen that radiates into their back. B. States pain began approximately 12 hr ago and is worse when they are supine or after they eat. C. Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow. D. Heart rate regular, lungs clear to auscultation. E. Abdomen firm, bowel sounds hypoactive. F. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. G. Reports no recent illnesses takes no prescribed medications. H. Client is alert and oriented x4.

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

Explanation

Rationale for Correct Choices:

Pain radiating to the back, worsens after eating or lying down: This is characteristic of acute pancreatitis, where inflammation irritates surrounding tissues and worsens in the supine position due to gravitational pressure. Postprandial worsening suggests pancreatic enzyme stimulation.
Scleral icterus (yellow sclera and palate): Jaundice suggests biliary obstruction or liver involvement, possibly due to gallstone pancreatitis or alcoholic liver disease. This also aligns with the elevated bilirubin levels and warrants further hepatic and biliary assessment.
Abdomen distended, rigid, and tender with guarding: These are signs of peritonitis or severe intra-abdominal inflammation, requiring urgent evaluation. Guarding and rigidity indicate localized or diffuse peritoneal irritation from pancreatic enzymes.
Hypoactive bowel sounds: Reduced bowel activity is often seen in pancreatitis due to paralytic ileus caused by inflammation and stress response. Monitoring for progression to ileus or obstruction is necessary.
Client guards abdomen and grimaces during palpation: Guarding and pain upon palpation are signs of significant intra-abdominal inflammation. It may reflect worsening pancreatitis or complications such as necrosis or peritonitis.

Rationale for Incorrect Choices:

Heart rate regular, lungs clear to auscultation: These are normal findings and do not require follow-up.
Client is alert and oriented x4: Indicates normal neurologic status. No immediate concern here.
Reports no recent illnesses, takes no prescribed medications: This helps rule out medication-induced pancreatitis and doesn't indicate a need for follow-up.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the parent?

Correct Answer is D

Explanation

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

Explanation

A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (Select all that apply.)

A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications?

A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?

A nurse is caring for a client at the clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by dropdown.