A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis.
Which of the following information should the nurse include in the instructions?
"I will need to give you Rh(D) immune globulin because you are Rh positive.”
"You will need to have an empty bladder for the test.”
"You will have to lie on your left side during the test.”
"You will have to drink 50 grams of oral glucose before the test.”
The Correct Answer is B
Choice A rationale:
The administration of Rh(D) immune globulin (RhoGAM) is typically indicated for Rh-negative mothers who are carrying Rh-positive fetuses to prevent sensitization to Rh antigens. It is not directly related to the amniocentesis procedure. Therefore, this information is not necessary for the client undergoing an amniocentesis.
Choice B rationale:
This is the correct answer. Having an empty bladder is crucial during an amniocentesis procedure because a full bladder can obscure visualization of the fetus and the needle placement. It is essential for a successful and safe procedure. The nurse should instruct the client to empty their bladder before the test.
Choice C rationale:
The position during an amniocentesis is typically dorsal recumbent or semi-Fowler's position to allow for proper visualization of the fetus and needle placement. Lying on the left side is not a standard position for this procedure, so this information is incorrect and not necessary for the client.
Choice D rationale:
Drinking 50 grams of oral glucose is not a requirement for an amniocentesis procedure. This information is unrelated to the amniocentesis and can be confusing for the client. Therefore, it is not necessary to include this in the instructions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale:
Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.
Choice B rationale:
The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.
Choice C rationale:
Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.
Choice D rationale:
A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.
Choice E rationale:
Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.
Choice F rationale:
Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.
Choice G rationale:
A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.
Correct Answer is C
Explanation
Choice A rationale:
Hypertension (high blood pressure) is not typically associated with hyponatremia. Hyponatremia is characterized by low levels of sodium in the blood, which can lead to symptoms such as headache, nausea, vomiting, confusion, and muscle cramps. Hypertension is more commonly associated with conditions like hypertension itself or conditions that cause fluid retention.
Choice B rationale:
Constipation is not a typical finding in hyponatremia. Hyponatremia is more likely to cause gastrointestinal symptoms such as nausea and vomiting. Constipation is not a direct consequence of low sodium levels in the blood.
Choice C rationale:
Muscle cramps are a common manifestation of hyponatremia. Low sodium levels can lead to an imbalance in electrolytes, affecting muscle function and leading to muscle cramps and weakness. Monitoring for muscle cramps is important in clients with hyponatremia.
Choice D rationale:
Blurred vision is not a classic symptom of hyponatremia. Hyponatremia is more likely to cause neurological symptoms such as confusion, headache, and in severe cases, seizures. Blurred vision is typically associated with other eye or visual disorders and not directly related to low sodium levels in the blood.
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