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:
Maternal serum alpha-fetoprotein (MSAFP) determination is not used to screen for ABO incompatibility. It is specifically used to screen for certain fetal abnormalities.
Choice B rationale:
MSAFP determination is not used to screen for gestational diabetes. It is primarily used for detecting certain fetal abnormalities.
Choice C rationale:
The MSAFP test is a prenatal screening test that measures the level of alpha-fetoprotein in the mother's blood. Abnormal levels of alpha-fetoprotein may indicate a neural tube defect, such as spina bifida, or other chromosomal abnormalities.
Choice D rationale:
MSAFP determination is not used to screen for fetal maturity. It is used to assess the risk of certain fetal abnormalities.

A. Rooting B. Babinski C. Moro D. Stepping

Correct Answer is A

Explanation

Choice A rationale: The rooting reflex is a natural reflex in newborns that helps them find the nipple for feeding. When the baby's cheek is touched or stroked, they will turn their head in that direction and open their mouth, searching for the breast or bottle.
Choice B rationale: The Babinski reflex is a different reflex, which involves the fanning and curling of the toes when the sole of the foot is stroked. It is not related to sucking or feeding.
Choice C rationale: The Moro reflex, also known as the startle reflex, occurs when a newborn is startled by a sudden noise or movement. The baby reacts by extending their arms and legs and then bringing them back toward the center of their body. It is not related to sucking or feeding.
Choice D rationale: The stepping reflex is observed when a newborn is held upright with their feet touching a solid surface. The baby will make stepping movements, but it is not related to sucking or feeding.

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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

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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?