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 D

Explanation

Rationale:

A. Insert an indwelling urinary catheter: While important for monitoring urine output and renal perfusion, catheter insertion is not the immediate priority in a trauma situation. It should be done after vascular access is secured and life-threatening conditions are addressed.

B. Administer packed RBCs: Blood transfusion is critical for managing hemorrhagic shock, but it cannot be initiated until a large-bore IV is placed. Vascular access is necessary before any fluid or blood product administration.

C. Obtain a specimen for ABG analysis: ABGs provide valuable data on oxygenation and acid-base balance but are diagnostic rather than life-sustaining. This step is less urgent than establishing IV access for fluid resuscitation or transfusion.

D. Place a large-bore IV catheter in an upper extremity: In trauma care, rapid IV access is the top priority to allow fluid and blood product resuscitation. A large-bore catheter ensures high-volume administration, which is essential in potential hemorrhagic shock.

A. A client who requests assistance to use the bedside commode B. A client who requests to sit in the bedside chair while watching TV. C. A client who has a prescription for compression stockings and did not receive them. D. A client who consumes all the food from their meal tray

Correct Answer is C

Explanation

Rationale:

A. A client who requests assistance to use the bedside commode: This is a routine activity that falls within the scope of practice for assistive personnel. As long as the AP follows standard safety procedures, there is no immediate need to report this to the nurse.

B. A client who requests to sit in the bedside chair while watching TV: Allowing a client to sit up in a chair is within the AP’s role, provided the client is stable and fall precautions are followed. It does not require nurse notification unless there are complications.

C. A client who has a prescription for compression stockings and did not receive them: This indicates a potential lapse in prescribed therapy, which could increase the risk of complications like deep vein thrombosis. The nurse must be informed to evaluate and correct the omission promptly.

D. A client who consumes all the food from their meal tray: Reporting full meal consumption is not necessary unless the client is on a monitored diet or has specific nutritional concerns. In most cases, this is expected and requires only standard documentation.

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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

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Explanation

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Explanation

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