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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Charge nurse.
Choice b rationale: The charge nurse is the appropriate personnel to report the incorrect blood glucose monitoring by the assistive personnel. As the nurse in charge of the unit, the charge nurse has the authority and responsibility to address issues related to patient care and ensure that nursing staff, including assistive personnel, are providing care according to facility policies and procedures
Choice a rationale: While the nurse manager is responsible for overseeing the nursing staff and ensuring quality patient care, it is more appropriate to report the incident to the charge nurse first, as they are directly responsible for the unit and can immediately address the issue
Choice c rationale: The risk manager is responsible for identifying, assessing, and mitigating risks within the healthcare facility. While the incorrect blood glucose monitoring could be considered a risk, it is not the primary role of the risk manager to address issues related to patient care. The charge nurse is better positioned to address the immediate concern and ensure proper training or corrective action for the assistive personnel.
Choice d rationale: The nurse supervisor is responsible for overseeing and managing nursing staff, similar to the nurse manager. However, the charge nurse is the more appropriate personnel to report the incident to, as they are directly responsible for the unit and can immediately address the issue
Correct Answer is B
Explanation
Choice A rationale:
"Obtain a prescription for pramipexole." Rationale: This statement is not appropriate for a pregnant client experiencing trouble sleeping. Pramipexole is a medication used to treat restless legs syndrome and Parkinson's disease. It is not typically prescribed for sleep disturbances during pregnancy.
Choice B rationale:
"Lie on your left side with your top leg forward." Rationale: This is the correct instruction. The recommended sleeping position during pregnancy is lying on the left side with the top leg forward. This position can help improve blood flow to the uterus and relieve pressure on major blood vessels, promoting better sleep.
Choice C rationale:
"Use a transcutaneous electrical nerve stimulator." Rationale: Using a transcutaneous electrical nerve stimulator (TENS) is not a standard intervention for pregnancy-related sleep problems. TENS units are typically used for pain management and are not indicated for sleep disturbances.
Choice D rationale:
"Soak in a bathtub of hot water each night." Rationale: This recommendation is not appropriate during pregnancy. Soaking in hot water for extended periods can raise the body's core temperature, which is not recommended during pregnancy as it may pose a risk to the developing fetus. Pregnant individuals should avoid hot tubs, saunas, and prolonged exposure to hot water.
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