Nokea
The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
- A. Evaluate need for Rh0D immunoglobulin
- B. Clean site
- C. Administer pain medication
- D. Perform vital signs
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn.
Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.
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A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: The best time to schedule the ultrasound immediately is because in early pregnancy, it is crucial to confirm the gestational age, rule out ectopic pregnancy, and assess fetal viability. This allows for accurate dating, identification of potential complications, and timely interventions if needed. Waiting for 2, 4, or 6 weeks could delay necessary care and potentially compromise the well-being of the patient and the fetus. Early detection and management of any issues are essential in ensuring a healthy pregnancy outcome.
What is the rationale for a woman in her first trimester of pregnancy to expect to visit her health care provider every 4 weeks?
- A. Problems can be eliminated.
- B. She develops trust in the health care team.
- C. Her questions about labor can be answered.
- D. The conditions of the expectant mother and fetus can be monitored.
Correct Answer: D
Rationale: The correct answer is D because in the first trimester, regular monitoring is crucial to ensure the health and well-being of both the mother and fetus. Visiting every 4 weeks allows the healthcare provider to monitor the progress of the pregnancy, detect any potential issues early on, and provide appropriate interventions if needed. This frequency enables timely adjustments to care plans, such as dietary recommendations or medication changes, to optimize outcomes. Choices A, B, and C are incorrect as they do not directly relate to the primary reason for the regular visits during the first trimester, which is to monitor the conditions of the expectant mother and fetus.
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
- A. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results.
- B. Maintain NPO status prior to testing.
- C. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
- D. Have an infusion pump prepared with oxytocin per protocol for evaluation.
Correct Answer: C
Rationale: The correct answer is C because positioning the patient for comfort and adjusting the tocotransducer belt to locate fetal heart rate are essential steps in preparing a pregnant patient for a nonstress test (NST). This allows for proper monitoring of fetal heart rate without interference.
A: Having the patient void prior to the test is not necessary for an NST as a full bladder does not interfere with the results.
B: Maintaining NPO status is not required for an NST, as it does not involve any invasive procedures that would necessitate fasting.
D: Preparing an infusion pump with oxytocin is not part of the standard preparation for an NST and is not needed for evaluation.
The mother of a neonate with Down syndrome wishes to breastfeed. Which of the following considerations should the nurse make in relation to the mother’s wishes?
- A. The mother should be encouraged to feed expressed breast milk via a bottle.
- B. Down syndrome babies consume more calories than unaffected neonates.
- C. Because of the weight of the neonatal head, the side-lying position must be used.
- D. The baby will likely have a weak suck due to congenitally poor muscle tone.
Correct Answer: D
Rationale: Babies with Down syndrome often have hypotonia, which can affect their ability to suck effectively during breastfeeding.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.