A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

Empty her bladder immediately prior to the procedure.

Refrain from eating breakfast on the day of the procedure.

Give herself a hypertonic enema the day before the procedure.

Wash her abdomen with soap and water the morning of the procedure.

Answer and Explanation

The Correct Answer is A

Choice A rationale: An amniocentesis involves inserting a needle through the abdominal wall into the amniotic sac to obtain a sample of amniotic fluid. Emptying the bladder before the procedure reduces the risk of bladder puncture during the process.
Choice B rationale: Fasting is not typically necessary for an amniocentesis. It is generally done on an outpatient basis, and fasting is not required.
Choice C rationale: An enema is not necessary before an amniocentesis and is not part of the standard preparation.
Choice D rationale: While cleanliness is important, this instruction is not specific to an amniocentesis and is not a standard pre-procedure requirement.

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Correct Answer is C

Explanation

Choice A rationale: This statement is not accurate, as startling in response to a loud noise does not necessarily indicate that the baby can hear normally. Startling can be a normal reflex response and may not accurately assess the baby's hearing ability.
Choice B rationale: While it is true that many forms of hearing loss are not inherited, the client's concern about her family history of deafness is valid. It is essential to address her concerns and provide appropriate information about the hearing screening.
Choice C rationale: Routine hearing screenings are typically performed on newborns to identify any potential hearing problems early on. Early detection and intervention for hearing loss can lead to better outcomes for the baby's language development and overall well-being. By reassuring the client about the hearing screening, the nurse addresses her concerns and provides information about the process.
Choice D rationale: While visual cues and responses are important for the baby's communication and bonding, they do not provide a definitive assessment of the baby's hearing ability. Hearing screening is a more reliable method to detect potential hearing problems in newborns.

A. Place elbow restraints on the newborn. B. Change the newborn's position every 2 hr. C. Cluster the newborn's care activities. D. Allow opportunities for newborn massage.

Correct Answer is C

Explanation

Choice A rationale: Placing elbow restraints is not a recommended practice for preterm newborns. Restraints are used in some cases to prevent the baby from pulling on tubes or lines, but it is not primarily for energy conservation.
Choice B rationale: While frequent position changes are important to prevent pressure ulcers and promote comfort, they may not necessarily help conserve energy in a preterm newborn.
Choice C rationale: Preterm newborns have limited energy reserves, and conserving energy is essential for their growth and development. Clustering care activities involves combining nursing care tasks to allow for longer periods of uninterrupted rest for the baby. This approach reduces the baby's energy expenditure and promotes better weight gain and stability.
Choice D rationale: While gentle touch and massage can be beneficial for preterm newborns to promote bonding and relaxation, it may not directly conserve energy as cluster care does.

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A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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