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.”

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Avoiding the use of draw sheets for repositioning is not a direct intervention for managing urinary incontinence. Draw sheets are typically used for repositioning and preventing pressure injuries. Managing urinary incontinence involves strategies such as toileting schedules, absorbent products, and perineal care.

Choice B rationale:

Limiting periods of sitting in a chair to 4 hours is a general guideline for preventing pressure ulcers in individuals with limited mobility, but it is not specific to managing urinary incontinence. Clients with urinary incontinence may need to sit in chairs for extended periods, and it is essential to address incontinence management separately.

Choice C rationale:

Using a no-rinse perineal cleanser after incontinence is an appropriate intervention for maintaining skin hygiene and preventing irritation in individuals with urinary incontinence. No-rinse cleansers are designed to clean the perineal area without the need for rinsing, making them convenient for incontinence care. Choice D

A. Gently massage the eyelid to facilitate absorption of the medication. B. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days. C. Place an occlusive dressing on the affected eye to prevent the spread of infection. D. Wipe any excess medication from the inner canthus outward.

Correct Answer is D

Explanation

The correct answer is d. Wipe any excess medication from the inner canthus outward.

Choice A reason: Gently massaging the eyelid is not recommended because it does not facilitate the absorption of ophthalmic ointment and may cause additional irritation or spread the infection.

Choice B reason: The instruction is incorrect because the child has been prescribed bacitracin, not erythromycin. It’s important to follow the prescribed medication and dosage instructions.

Choice C reason: Placing an occlusive dressing over the eye is not advised for bacterial conjunctivitis as it can create a moist environment that may promote bacterial growth.

Choice D reason: This is the correct action. After applying the ointment, wiping away excess from the inner canthus outward prevents the spread of infection and keeps the area clean. This method prevents potential irritation and ensures that the medication does not obstruct vision.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?