A client who is at 22 weeks gestation is being educated by a nurse about the amniocentesis procedure. Which of the following statements should the nurse make?
- A. You will lie on your right side during the procedure.
- B. You should not eat anything for 24 hours before the procedure.
- C. You should empty your bladder before the procedure.
- D. The test is performed to determine gestational age.
Correct Answer: C
Rationale: The correct answer is C: You should empty your bladder before the procedure. This is important because a full bladder can obstruct the visualization of the fetus during amniocentesis. By emptying the bladder, the uterus is better positioned for the procedure, making it safer and more effective.
Explanation:
1. A (You will lie on your right side during the procedure) is incorrect because the position during amniocentesis is typically on the back or slightly tilted to the left.
2. B (You should not eat anything for 24 hours before the procedure) is incorrect as fasting is not required for amniocentesis.
3. D (The test is performed to determine gestational age) is incorrect as amniocentesis is used to detect genetic abnormalities, not gestational age.
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When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?
- A. Hgb 12.2 g/dL
- B. Urine ketones present
- C. Alanine aminotransferase 20 IU/L
- D. Blood glucose 114 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Urine ketones present. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy, leading to dehydration and ketonuria. Presence of urine ketones indicates fat breakdown due to inadequate calorie intake. Option A is within normal range for hemoglobin. Option C is within normal range for alanine aminotransferase. Option D is within normal range for blood glucose. Thus, the presence of urine ketones is the most indicative finding for hyperemesis gravidarum.
A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?
- A. Dark green leafy vegetables
- B. Deep red or orange vegetables
- C. White bread and rice
- D. Meat, poultry, and fish
Correct Answer: A
Rationale: The correct answer is A: Dark green leafy vegetables. Dark green leafy vegetables like kale, spinach, and broccoli are excellent sources of calcium. They provide a good alternative to dairy for those who don't like milk. These vegetables are rich in calcium, which is essential for bone health, especially during pregnancy. They also offer other nutrients like vitamin K and magnesium that support calcium absorption.
Summary:
B: Deep red or orange vegetables - While these vegetables are nutritious, they are not significant sources of calcium.
C: White bread and rice - These foods do not provide a significant amount of calcium.
D: Meat, poultry, and fish - While these foods are rich in protein and other nutrients, they are not primary sources of calcium.
When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
- A. Count the fetal heart rate for 15 seconds to determine the baseline.
- B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
- C. Count the fetal heart rate after a contraction to determine baseline changes.
- D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
A nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?
- A. Seeking an immunization against rubella early in pregnancy.
- B. Receiving prophylactic treatment for cytomegalovirus if detected during pregnancy.
- C. Clients should avoid crowded places during pregnancy.
- D. Clients should avoid consuming undercooked meat while pregnant.
Correct Answer: D
Rationale: The correct answer is D. Clients should avoid consuming undercooked meat while pregnant to prevent toxoplasmosis, a TORCH infection. Toxoplasmosis is commonly found in undercooked meat and can be harmful to the fetus. Seeking an immunization against rubella early in pregnancy (A) is important, but it does not prevent all TORCH infections. Prophylactic treatment for cytomegalovirus if detected during pregnancy (B) is not a standard practice. Avoiding crowded places during pregnancy (C) may reduce the risk of infections, but it is not specific to TORCH infections.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
- A. Palpate the fundus to identify the fetal part.
- B. Determine the location of the fetal back.
- C. Palpate for the fetal part presenting at the inlet.
- D. All of the Above
Correct Answer: D
Rationale: The correct sequence for performing Leopold maneuvers is to first palpate the fundus to identify the fetal part (A), then determine the location of the fetal back (B), and finally palpate for the fetal part presenting at the inlet (C). Choosing option D (All of the Above) is correct because it encompasses all the necessary steps in the correct order to perform Leopold maneuvers effectively. Palpating the fundus helps identify the presenting part, determining the location of the fetal back provides information on the fetal lie, and palpating for the presenting part at the inlet helps confirm the position of the fetus. The other choices are incorrect because they do not provide the complete sequence required for performing Leopold maneuvers accurately.