Nokea
A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the fetal heart rate (FHR).
Correct Answer: D
Rationale: The correct answer is D: Monitor the fetal heart rate (FHR). After an amniocentesis, the priority is monitoring FHR to assess fetal well-being and detect any signs of distress. This is crucial as the procedure carries a risk of causing fetal distress. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is important but not immediate post-amniocentesis. Administering Rho(D) immune globulin (C) is typically done in cases of Rh incompatibility and not directly related to the amniocentesis procedure.
You may also like to solve these questions
When teaching a new mother how to use a bulb syringe to suction her newborn's secretions, which of the following instructions should the nurse include?
- A. Insert the syringe tip after compressing the bulb.
- B. Suction each nare before suctioning the mouth.
- C. Insert the tip of the syringe at the center of the newborn's mouth.
- D. Stop suctioning when the newborn's cry sounds clear.
Correct Answer: D
Rationale: The correct answer is D because it is important to stop suctioning when the newborn's cry sounds clear to avoid causing unnecessary discomfort or injury. Step 1: Gently compress the bulb syringe. Step 2: Insert the tip into the nostril, not the mouth. Step 3: Release the bulb to suction out the secretions. Step 4: Repeat in the other nostril. Incorrect choices: A is incorrect because you should insert the syringe tip before compressing the bulb. B is incorrect as you should suction the mouth before the nose. C is incorrect as you should not insert the syringe tip in the center of the mouth.
A client at 8 weeks of gestation with iron deficiency anemia is prescribed iron supplements. Which beverage should the nurse reinforce the client to take the supplements with for better absorption?
- A. Ice water
- B. Low-fat or whole milk
- C. Tea or coffee
- D. Orange juice
Correct Answer: D
Rationale: The correct answer is D: Orange juice. Vitamin C enhances iron absorption by converting non-heme iron to a more absorbable form. The acidity in orange juice aids in this process. Ice water (choice A) does not contain any nutrients to enhance iron absorption. Low-fat or whole milk (choice B) contains calcium, which can inhibit iron absorption. Tea or coffee (choice C) contains tannins that can also inhibit iron absorption. In summary, orange juice is the best choice due to its vitamin C content that helps improve iron absorption.
A client who is pregnant states that her last menstrual period was April 1st. What is the client's estimated date of delivery?
- A. January 8
- B. January 15
- C. February 8
- D. February 15
Correct Answer: A
Rationale: The estimated date of delivery (EDD) is calculated by adding 280 days to the first day of the last menstrual period (LMP). In this case, April 1st + 280 days = January 8, which is the correct EDD. Choice A is correct. Choices B, C, and D are incorrect because they do not account for the 280-day gestation period from the LMP.
A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include?
- A. Eat crackers or plain toast before getting out of bed
- B. Awaken during the night to eat a snack
- C. Skip breakfast and eat lunch after nausea has subsided
- D. Eat a large evening meal
Correct Answer: A
Rationale: The correct answer is A: Eat crackers or plain toast before getting out of bed. This recommendation helps alleviate morning sickness by providing a small, easily digestible snack to settle the stomach before getting up. It helps stabilize blood sugar levels and prevent an empty stomach exacerbating nausea.
Explanation for why B, C, and D are incorrect:
B: Awakening during the night to eat a snack can disrupt sleep patterns and is not necessary for managing morning sickness.
C: Skipping breakfast and waiting until lunch may lead to prolonged nausea and low blood sugar levels, worsening symptoms.
D: Eating a large evening meal can increase the likelihood of acid reflux and indigestion, making morning sickness worse.
A client in active labor at 39 weeks of gestation is receiving continuous IV oxytocin and has early decelerations in the FHR on the monitor tracing. What action should the nurse take?
- A. Discontinue the oxytocin infusion.
- B. Continue monitoring the client.
- C. Request that the provider assess the client.
- D. Increase the infusion rate of the maintenance IV fluid.
Correct Answer: B
Rationale: The correct action for the nurse to take when a client in active labor at 39 weeks of gestation has early decelerations in the FHR on the monitor tracing is to continue monitoring the client. Early decelerations are typically benign and are associated with head compression during contractions, which is a normal response to labor. There is no need to discontinue the oxytocin infusion as early decelerations do not indicate fetal distress. Requesting the provider to assess the client may not be necessary at this point unless other concerning signs are present. Increasing the infusion rate of the maintenance IV fluid is not indicated as it would not address the early decelerations. Therefore, the best course of action is to continue monitoring the client for any changes in the FHR pattern.