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 D
Explanation
Choice A rationale:
While music therapy can be a helpful adjunct for pain management, it is not a replacement for all pain medications. Pain management should be individualized, and the statement that music therapy alone will eliminate the need for all medication is not accurate.
Choice B rationale:
Discontinuing music therapy when the patient is no longer responsive may not be the best approach. Music therapy can still provide comfort and support even if the patient is not responsive in the traditional sense. It should be continued if it benefits the patient.
Choice C rationale:
Playing music is not intended to increase alertness but rather to provide comfort and relaxation. This statement reflects a misunderstanding of the purpose of music therapy in pain management.
Choice D rationale:
This statement correctly indicates an understanding of the purpose of music therapy. Music can distract the patient from pain and provide a sense of comfort and relaxation without completely eliminating awareness of pain.
Correct Answer is D
Explanation
Choice A rationale:
"This medication will darken the color of my eyes." This statement is not accurate. Timolol eye drops, which are commonly used to treat glaucoma, do not darken the color of the eyes. This statement indicates a misunderstanding of the medication's effects.
Choice B rationale:
"This medication will dilate my eyes." This statement is not accurate either. Timolol is a beta-blocker that works to reduce intraocular pressure by decreasing the production of aqueous humor in the eye. It does not dilate the eyes; in fact, it has the opposite effect.
Choice C rationale:
"I should take a zinc supplement while taking this medication." This statement is unrelated to the use of timolol eye drops for glaucoma and is not part of the standard treatment plan. There is no established connection between taking zinc supplements and using timolol for glaucoma management.
Choice D rationale:
"I should check my heart rate while taking this medication." This statement indicates an understanding of the teaching. Timolol is a beta-blocker that can lower heart rate and blood pressure. Clients using timolol eye drops should be advised to monitor their heart rate regularly and report any significant changes to their healthcare provider. This is important for safety and to ensure that the medication is not causing any adverse cardiovascular effects.
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