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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale: The gender of the fetus is not determined through amniocentesis. Fetal gender determination can be achieved through ultrasound or other specialized genetic tests if needed.
Choice B rationale: While amniocentesis can provide information about certain chromosomal abnormalities and genetic conditions, it is not the primary procedure used to detect anatomic abnormalities. Detailed ultrasound and other specialized imaging techniques are used for this purpose.
Choice C rationale: Amniocentesis is a prenatal diagnostic procedure in which a small amount of amniotic fluid is withdrawn from the uterus. The amniotic fluid contains fetal cells and biochemical substances that can provide valuable information about the fetus's health and development. One of the essential pieces of information obtained from amniocentesis is the maturity of the lungs. This is crucial in preterm labor to assess whether the lungs are mature enough to support breathing if the baby is born prematurely.
Choice D rationale: The gestational age is determined through other methods, such as ultrasound measurements and the last menstrual period. Amniocentesis is not primarily used to determine the weeks of gestation.
Correct Answer is A
Explanation
Choice A rationale: The Moro reflex, also known as the startle reflex, is elicited by making a loud noise or performing a sharp hand clap near the newborn. In response to the stimulus, the newborn will throw their arms and legs outward and then bring them back toward the center of the body.
Choice B rationale: Placing a finger at the base of the newborn's toes is not related to eliciting the Moro reflex. This action may elicit the Babinski reflex, which causes the toes to fan out and the big toe to dorsiflex.
Choice C rationale: This action may elicit the stepping reflex, where the newborn will make stepping movements when the soles of their feet touch a flat surface. It is not related to eliciting the Moro reflex.
Choice D rationale: Turning the newborn's head quickly to one side is not related to eliciting the Moro reflex. This action may elicit the asymmetric tonic neck reflex (ATNR), where the newborn will extend the arm and leg on the side their head is turned to and flex the opposite arm and leg.
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