A nurse is preparing to perform an amniocentesis on a client who is at 27 weeks of gestation and has pre-term labor.
Which of the following actions should the nurse take before the procedure?
Administer tocolytic medication to stop contractions
Instruct the client to empty her bladder
Obtain informed consent from the client
Monitor fetal heart rate and activity
The Correct Answer is B
Instruct the client to empty her bladder. This is because a full bladder can interfere with the insertion of the needle and increase the risk of injury to the bladder or the uterus. Emptying the bladder also reduces discomfort during the procedure.
Choice A is wrong because administering tocolytic medication to stop contractions is not necessary before amniocentesis. Tocolytic medication can have side effects and should only be used when there is a clear indication of preterm labor.
Choice C is wrong because obtaining informed consent from the client is not a nursing action, but a medical one. The nurse can assist in providing information and answering questions, but the final consent should be obtained by the doctor who will perform the procedure.
Choice D is wrong because monitoring fetal heart rate and activity is not a specific action before amniocentesis, but a routine part of prenatal care. Fetal heart rate and activity can be affected by many factors, such as maternal position, fetal sleep cycle, or maternal blood sugar level.
Monitoring them before amniocentesis does not provide any useful information for the procedure.
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Correct Answer is B
Explanation
Drinking enough water can help prevent dehydration, which can trigger preterm labor contractions.Dehydration can also cause low amniotic fluid levels, which can affect fetal growth and development.
Choice A is wrong because avoiding sexual intercourse until term is not necessary for most women at risk for preterm labor.Sexual activity does not cause preterm labor unless there are other complications, such as placenta previa or cervical insufficiency.
Choice C is wrong because lying down when feeling contractions may not stop preterm labor.If a woman has regular contractions that cause cervical change, she should seek medical attention as soon as possible.Lying down may also reduce blood flow to the uterus and placenta, which can affect fetal oxygenation.
Choice D is wrong because taking aspirin for pelvic pain is not recommended for pregnant women.Aspirin can increase the risk of bleeding and affect fetal blood circulation.
Pelvic pain may be a sign of preterm labor or other complications, so it should be evaluated by a health care provider
Correct Answer is A
Explanation
Nitrazine paper test.
This test involves putting a drop of fluid obtained from the vagina onto paper strips containing nitrazine dye.
The strips change color depending on the pH of the fluid.The strips will turn blue if the pH is greater than 6.0, which indicates the presence of amniotic fluid.This test can help confirm rupture of membranes (ROM) in pregnancy, especially when preterm labor is suspected.
Choice B. Ferning test.This test involves examining a sample of vaginal fluid under a microscope and looking for a fern-like pattern that is formed by dried amniotic fluid crystals.This test can also help confirm ROM, but it is less reliable than the nitrazine test because other substances such as cervical mucus, semen, or blood can also cause ferning.
Choice C. Amniotic fluid index.This test involves measuring the amount of amniotic fluid in the uterus using ultrasound.This test can help assess the fetal well-being and detect conditions such as oligohydramnios (low amniotic fluid) or polyhydramnios (high amniotic fluid).This test cannot confirm ROM by itself, but it can be used in combination with other tests to evaluate the status of the pregnancy.
Choice D. Biophysical profile.This test involves using ultrasound and a fetal monitor to assess the fetal heart rate, breathing, movement, muscle tone, and amniotic fluid volume.
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