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.

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Correct Answer is C

Explanation

Rationale:

A. Hypertension: Dehydration in infants typically causes hypotension, not hypertension, due to reduced circulating volume and poor perfusion as fluid loss progresses.

B. Decreased temperature: While temperature may fluctuate in dehydration, fever is more common due to infection-related fluid loss. A decreased temperature is not a consistent sign.

C. Oliguria: Decreased urine output is a key indicator of dehydration in infants. The kidneys conserve water during hypovolemia, resulting in oliguria (less than 1 mL/kg/hr).

D. Bulging anterior fontanel: A bulging fontanel usually indicates increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel in infants.

A. Insert a nasogastric tube and maintain low intermittent suction. B. Administer IV lactated Ringer's C. Insert an indwelling urinary catheter D. Administer IV famotidine

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationale:

Insert a nasogastric tube and maintain low intermittent suction: This is anticipated to help decompress the stomach, reduce nausea and vomiting, and prevent aspiration in a client with severe pancreatitis who is vomiting and has abdominal distension.
Administer IV lactated Ringer's: IV fluids are critical for hydration and to correct electrolyte imbalances in acute pancreatitis. Lactated Ringer’s is preferred over normal saline because it better maintains acid-base balance.
Insert an indwelling urinary catheter: This is generally contraindicated unless necessary, as it increases the risk of infection. No information indicates urinary retention or need for strict output monitoring that outweighs infection risks.
Administer IV famotidine: Famotidine reduces gastric acid secretion, which helps protect the gastric mucosa and may be beneficial in preventing stress ulcers in critically ill clients. It is appropriate in this situation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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