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 A
Explanation
Choice A rationale:
The nurse should respond by offering to show the client how to swaddle and cuddle the newborn and then encourage the client to try it herself. This response promotes bonding between the mother and newborn and empowers the client to care for her baby, building her confidence and self-esteem.
Choice B rationale:
Taking the newborn back to the nursery without involving the mother does not support maternal-infant bonding and does not address the client's feelings of inadequacy. It is essential to encourage maternal involvement in infant care.
Choice C rationale:
Turning the newborn on his side without addressing the client's concerns does not provide emotional support or guidance on infant care. It is important to respond to the client's emotional needs and offer assistance in caring for the baby.
Choice D rationale:
Telling the client that babies need to cry to develop their lungs is not an appropriate response to the client's distress. It does not address the client's concerns or provide helpful guidance on caring for the newborn.
Correct Answer is A
Explanation
Choice A rationale:
"I should have my baby latch on to my nipple and areola during feeding." Rationale: This is the correct statement and indicates an understanding of breastfeeding. Proper latch involves the baby taking both the nipple and a portion of the areola into their mouth. This ensures effective milk transfer and prevents nipple pain and damage.
Choice B rationale:
"I should not wake my baby during the night to breastfeed." Rationale: While it is generally recommended to let a newborn sleep for longer stretches at night, it's essential to ensure the baby feeds frequently, especially in the early days. Waking the baby for feedings, at least every 2-3 hours, is important to establish a good milk supply and ensure the baby's nutritional needs are met.
Choice C rationale:
"My baby should breastfeed 5 to 10 minutes on each breast." Rationale: This statement is not entirely accurate. The duration of breastfeeding can vary from baby to baby. It's essential to allow the baby to feed as long as they want on the first breast, ensuring they get the hindmilk, which is rich in fat and essential for growth. The baby may switch to the other breast when they are ready.
Choice D rationale:
"I should keep my baby on a strict feeding schedule." Rationale: This statement is not correct. Breastfeeding is demand-driven, and it's important to feed the baby when they show hunger cues, which may not always align with a strict schedule. Feeding on demand helps ensure the baby receives enough nourishment and promotes milk supply.
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