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A nurse is reinforcing teaching to a client who will undergo amniocentesis. Which of the following statements should the nurse make?

A.

This test detects fetal genetic abnormalities.

B.

An empty bladder is required for the test.

C.

An x-ray will be taken during needle placement.

D.

This test determines the volume of amniotic fluid.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Amniocentesis is used to detect fetal genetic abnormalities, such as Down syndrome, by analyzing the amniotic fluid for genetic markers.

 

Choice B rationale

 

An empty bladder is required for the test only in late pregnancy to prevent bladder injury; however, in early pregnancy, a full bladder may be required to better visualize the uterus and amniotic fluid.

 

Choice C rationale

 

An x-ray is not typically used during the needle placement for amniocentesis. Ultrasound is the preferred method to guide the needle to avoid harm to the fetus and mother.

 

Choice D rationale

 

The test does not determine the volume of amniotic fluid; it is used primarily for genetic analysis, assessing fetal lung maturity, and diagnosing certain fetal infections.

 


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Correct Answer is C

Explanation

Choice A rationale

A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.

Choice B rationale

Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.

Choice C rationale

This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.

Choice D rationale

An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .

Correct Answer is D

Explanation

Choice A rationale

An apical pulse of 66/min is within the normal range and not indicative of postpartum hemorrhage, which would typically cause an elevated heart rate due to blood loss.

Choice B rationale

A temperature of 38.3°C (101°F) could indicate infection or inflammation but is not a direct sign of postpartum hemorrhage, which primarily involves significant blood loss.

Choice C rationale

Blood pressure of 156/80 mm Hg is elevated but not directly indicative of postpartum hemorrhage, which would typically result in a drop in blood pressure due to loss of blood volume.

Choice D rationale

A respiratory rate of 32/min is significantly elevated and can be a compensatory response to hypovolemia from postpartum hemorrhage. This response occurs as the body tries to increase oxygen delivery due to blood loss.

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