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 A

Explanation

Rationale:

Using proper body mechanics is vital to prevent injury and ensure safe lifting. Key principles include keeping the back straight and neutral to reduce spinal stress and bending at the knees and hips to engage stronger leg muscles rather than the lower back. Maintaining a shoulder-width stance provides stability, while holding objects close to the body decreases spinal strain. Lifting with the legs, not the back, further protects the spine. Twisting should be avoided—pivoting with the feet maintains alignment and reduces injury risk. Keeping the head and neck aligned with the spine improves posture and visual focus. Using smooth, controlled movements prevents muscle strain and dropped objects. Assessing an object’s weight before lifting helps determine if help or equipment is needed, preventing overexertion. Supportive footwear with a good grip ensures balance and minimizes fall risk. These ergonomic practices promote safety, reduce injuries, and are essential in both clinical and everyday environments.

A. Place the client in a supine position. B. Remind the client to eat scheduled meals daily. C. Speak in a loud tone when addressing the client. D. Offer the client a blanket to keep warm.

Correct Answer is D

Explanation

Rationale:

A. Place the client in a supine position: The supine position may impair respiratory function and increase discomfort, especially in terminal clients who may experience dyspnea. A semi-Fowler’s or side-lying position is often preferred for comfort and easier breathing.

B. Remind the client to eat scheduled meals daily: For clients nearing end of life, appetite naturally decreases, and forcing meals can cause distress. Care should focus on comfort, allowing the client to eat only if and when they desire rather than adhering to structured meal times.

C. Speak in a loud tone when addressing the client: Loud speech is not appropriate unless the client has documented hearing impairment. A calm, soft tone is more comforting and respectful, especially in the emotionally sensitive context of end-of-life care.

D. Offer the client a blanket to keep warm: Clients nearing the end of life often experience poor circulation and may feel cold. Providing a blanket is a comfort-focused, non-invasive intervention that promotes warmth and dignity during this phase.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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