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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: While colostrum is present in the first few days after delivery, it takes a few more days for breast milk to "come in" and increase in volume.
Choice B rationale: Waiting for 6 to 8 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
Choice C rationale: Colostrum, the first milk, is typically produced in small amounts during the first few days after delivery. Breast milk usually "comes in" or increases in volume around 3 to 5 days after childbirth. This transition from colostrum to mature milk is normal and expected.
Choice D rationale: Waiting for 10 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
Correct Answer is A
Explanation
Choice A rationale: Auscultating fetal heart tones in the right upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal back is on the right side of the mother's abdomen, and the fetal head is in the fundal portion of the uterus.
Choice B rationale: During Leopold maneuvers, the nurse palpated a round, firm, movable part in the fundal portion of the uterus. This finding corresponds to the fetal head, which is typically located at the top of the uterus (fundus). Additionally, the nurse palpated a long, smooth surface on the mother's right side. This finding indicates the fetal back, which typically lies along the right side of the mother's abdomen, suggesting that the fetus's back is positioned anteriorly (toward the mother's front). The location of the fetal heart is typically best heard over the back of the fetus. Therefore, the nurse should auscultate the fetal heart tones in the maternal quadrant corresponding to the back of the fetus, which is the left lower quadrant.
Choice C rationale: The information from Leopold maneuvers does not indicate the fetal back is in the right lower quadrant. The nurse should not auscultate fetal heart tones in this area.
Choice D rationale: Auscultating fetal heart tones in the left upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal head is in the fundal portion of the uterus and the fetal back is on the right side of the mother's abdomen. The fetal heart is usually best heard over the back of the fetus, which is not in the left upper quadrant.
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