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 D
Explanation
Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.
Correct Answer is A
Explanation
Choice A rationale: Drying the newborn and covering the head are essential steps in the immediate care of a newborn after birth. This helps prevent heat loss and promotes thermal stability for the baby.
Choice B rationale: Stimulating the newborn to cry is not the first priority in the immediate post-birth care. Drying and keeping the baby warm are more critical at this stage.
Choice C rationale: Clearing the respiratory tract may be necessary if there are signs of respiratory distress, but it is not the first action in the routine care of a newborn immediately after delivery.
Choice D rationale: Clamping the umbilical cord is usually done after the immediate care of the newborn is addressed, and it is not the first step in the initial care following a vaginal delivery.
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