Choice A rationale:

Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia, but it can lead to respiratory depression and toxicity when levels become too high. Administering calcium gluconate helps counteract the effects of magnesium toxicity by competing for binding sites and restoring neuromuscular function. This is the appropriate treatment to address the client's symptoms of respiratory depression, which are suggestive of magnesium sulfate toxicity.

Choice B rationale:

Flumazenil is not the correct choice in this situation. Flumazenil is a medication used to reverse the effects of benzodiazepine overdose, not magnesium sulfate toxicity. It does not have any impact on magnesium levels or their associated toxic effects.

Choice C rationale:

Naloxone is used to reverse the effects of opioids, such as morphine or fentanyl. It is not indicated for magnesium sulfate toxicity. Administering naloxone would not address the client's symptoms or the underlying cause of respiratory depressionzz.

Choice D rationale:

Protamine sulfate is an antidote used to reverse the anticoagulant effects of heparin, not magnesium sulfate. It is not effective in treating magnesium sulfate toxicity. Administering protamine sulfate would not be the appropriate intervention for this situation.

Choice A rationale:

To prevent thrombophlebitis in a postpartum client following a cesarean birth, it is important to promote good circulation and prevent stasis of blood in the lower extremities. Placing pillows under the client's knees while she is resting in bed helps elevate the legs slightly and promotes better venous return, reducing the risk of thrombophlebitis. This position facilitates improved circulation and is a recommended practice.

Choice B rationale:

Applying hot moist soaks to the client's lower legs is not a recommended intervention to prevent thrombophlebitis. In fact, heat can increase inflammation and may worsen the condition. This option would not contribute to the client's plan of care for thrombophlebitis prevention.

Choice C rationale:

Assisting the client to ambulate in the hallway is a good practice to prevent thrombophlebitis, but it may not be suitable for a client who is only 1 day postpartum following a cesarean birth. Early ambulation is encouraged but should be done gradually and at the client's own pace to avoid undue stress on the incision site. Placing pillows under the knees while resting in bed is a more appropriate initial intervention.

Choice D rationale:

Keeping the client on bed rest is not the best option for preventing thrombophlebitis in a postpartum client. Immobility can increase the risk of stasis and clot formation. Promoting circulation, such as elevating the legs with pillows, is a more effective strategy to reduce the risk of thrombophlebitis.

Choice A rationale:

Blotting the perineal area dry after voiding is an important part of perineal care. Moisture can contribute to perineal infection, so it is essential to keep the area dry. This practice helps prevent the growth of bacteria and reduces the risk of infection.

Choice D rationale:

Cleaning the perineal area from front to back is crucial in reducing the risk of perineal infection. This method helps prevent the transfer of bacteria from the anal area to the perineum and vaginal area, reducing the risk of infection.

Choice E rationale:

Performing hand hygiene before and after voiding is an important aspect of perineal care and infection prevention. Proper hand hygiene helps prevent the transfer of bacteria from the hands to the perineal area and vice versa, reducing the risk of infection.

Choice B rationale:

Applying ice packs to the perineal area several times daily is not a recommended practice for reducing the risk of perineal infection. While ice packs can provide pain relief and reduce swelling, they should not be applied excessively, as prolonged exposure to cold can compromise blood flow and potentially increase the risk of tissue damage or infection.

Choice C rationale:

Sitting on an inflatable donut to protect the perineum is not a recommended practice for reducing the risk of perineal infection. Inflatable donuts can increase pressure on the perineal area, potentially causing discomfort and impairing blood flow. Proper hygiene and keeping the area clean and dry are more effective strategies for infection prevention. .

A nurse is reinforcing nutritional teaching with a client who is at 8 weeks of gestation. Which of the following statements should the nurse include? The correct answer is choice B: "You should increase your folic acid intake during your pregnancy.”.

Choice A rationale:

"You should stop taking your prenatal vitamin if you experience nausea.”. This statement is incorrect. Nausea is a common symptom during pregnancy, especially during the first trimester. However, discontinuing prenatal vitamins is not recommended. It's essential to continue taking them to ensure the mother and baby receive adequate nutrients. Prenatal vitamins are designed to provide essential vitamins and minerals that are crucial for the baby's development. Discontinuing them due to nausea could lead to nutrient deficiencies.

Choice C rationale:

"You should limit your iron intake during your first trimester.”. This statement is incorrect. Iron intake should not be limited during the first trimester. Iron is an essential mineral during pregnancy, as the mother's blood volume increases, and iron is required to make more red blood cells to carry oxygen to the baby. Iron deficiency can lead to anemia, which can be harmful to both the mother and the baby. Therefore, iron intake is typically increased during pregnancy to meet the increased demand.

Choice D rationale:

"You should increase your daily calorie intake by 750 calories.”. This statement is not entirely accurate. While it's true that calorie needs increase during pregnancy, the recommended additional calorie intake is generally around 300-500 calories per day, not 750. The exact number can vary from person to person, depending on their pre-pregnancy weight and activity level. Consuming too many extra calories can lead to excessive weight gain, which can have negative consequences for both the mother and the baby. It's important to focus on the quality of calories consumed and ensure they come from nutrient-dense foods.

A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? The correct answer is choice D: "You will need an immunization following delivery.”.

Choice A rationale:

"You had the rubella infection as a child.”. This statement is incorrect. A negative rubella titer indicates that the client is not immune to rubella. Even if the client had the infection as a child, it does not guarantee immunity for life. Immunity can wane over time, and some individuals may not have developed sufficient immunity after a natural infection.

Choice B rationale:

"I will administer the rubella immunization to you today.”. This statement is not recommended. Rubella vaccination is a live attenuated vaccine, and it is generally contraindicated during pregnancy due to the theoretical risk of transmission to the fetus. Rubella vaccination is usually recommended postpartum if the woman is not immune. The nurse should not administer the vaccine during pregnancy.

Choice C rationale:

"You are immune to rubella.”. This statement is incorrect. A negative rubella titer clearly indicates that the client is not immune to rubella. It's crucial for healthcare providers to provide accurate information to the client and ensure that appropriate immunization is administered postpartum to protect both the mother and the newborn.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions? The correct answer is choice B: Placenta previa.

Choice A rationale:

"Abruptio placentae.”. This choice is incorrect. Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can result in painful and dark red vaginal bleeding. It is associated with abdominal pain and fetal distress. In this case, the bleeding is described as painless and bright red, which is more indicative of placenta previa.

Choice C rationale:

"Preterm labor.”. This choice is incorrect. Preterm labor involves regular uterine contractions that result in cervical changes before 37 weeks of gestation. Painless, bright red vaginal bleeding is not typically associated with preterm labor. It is more often seen in placenta previa.

Choice D rationale:

"Threatened abortion.”. This choice is incorrect. Threatened abortion refers to vaginal bleeding in the first half of pregnancy, typically accompanied by mild uterine cramping. The bleeding is often associated with the possibility of miscarriage. However, the scenario described in the question occurs at 36 weeks of gestation, which is well into the third trimester and not within the typical timeframe for a threatened abortion.

Choice A rationale:

Maternal hypertension is the most common risk factor for placental abruption. Placental abruption is a serious condition where the placenta partially or completely separates from the uterine wall before the baby is born. This separation can lead to significant bleeding, which is a medical emergency. Hypertension, also known as high blood pressure, can cause damage to the blood vessels in the placenta, making it more likely for placental abruption to occur. High blood pressure can lead to decreased blood flow to the placenta, increasing the risk of separation.

Choice B rationale:

Maternal battering, while a concerning issue during pregnancy, is not the most common risk factor for placental abruption. Placental abruption is primarily associated with maternal medical conditions and factors that affect the uterine environment.

Choice C rationale:

Maternal cigarette smoking can have adverse effects on pregnancy, but it is not the most common risk factor for placental abruption. Smoking is more commonly associated with other complications such as low birth weight and preterm birth.

Choice D rationale:

Maternal cocaine use is a risk factor for placental abruption, but it is not the most common one. Cocaine can constrict blood vessels and reduce blood flow to the placenta, increasing the risk of abruption. However, hypertension remains the most prevalent risk factor.

Choice A rationale:

"Tell me more about your concerns" is an appropriate therapeutic response by the nurse. It encourages the client to express her worries and fears about the pelvic examination. Open-ended questions like this one allow the nurse to better understand the client's specific concerns, which can help in addressing them effectively.

Choice B rationale:

"All you need to do is relax during the exam" may come across as dismissive and may not address the client's anxiety effectively. It's important to acknowledge the client's feelings and offer support rather than making the situation seem overly simplistic.

Choice C rationale:

"Don't worry. I will stay in there with you for the exam" might make the client feel like she has no control over the situation and can be invasive. While offering support is important, it's essential to respect the client's autonomy and provide emotional support through active listening and communication.

Choice D rationale:

"A pelvic exam is required if you want birth control pills" is not an appropriate response to the client's anxiety about the pelvic exam. This response does not address the client's concerns and may not provide the necessary emotional support or information she needs.

Choice A rationale:

Administering the measles, mumps, rubella (MMR) vaccine two weeks before attempting pregnancy again is not the correct timing. It is important to provide the MMR vaccine postpartum before the client is discharged from the hospital after giving birth. This timing is appropriate to protect the woman from rubella and to avoid vaccinating during pregnancy.

Choice B rationale:

The correct timing for the MMR vaccine is prior to discharge from the hospital after giving birth. This approach ensures that the woman is protected against rubella before leaving the hospital and potentially becoming pregnant again. It is crucial to avoid vaccinating during pregnancy because the MMR vaccine contains live attenuated viruses.

Choice C rationale:

Administering the MMR vaccine prior to giving birth is not the recommended timing. Vaccination should be done postpartum to avoid any potential risks to the developing fetus.

Choice D rationale:

Administering the MMR vaccine when the client does not desire future pregnancies is not the most appropriate option. The vaccine should be given postpartum to protect the woman and any future pregnancies from rubella. It is important to provide vaccination recommendations based on evidence-based guidelines and the client's specific situation.

Choice A rationale:

To calculate the amount of vitamin K (1 mg) to administer, you need to use the given concentration (1 mg/0.5 mL). This means that 1 mg is present in every 0.5 mL of the solution. To determine how many milliliters (mL) you should administer to get 1 mg, you can set up a proportion: 1 mg / X mL = 1 mg / 0.5 mL Cross-multiply and solve for X: X = (1 mg * 0.5 mL) / 1 mg X = 0.5 mL Therefore, the nurse should administer 0.5 mL, which can be rounded to 2.0 mL to the nearest tenth of a milliliter. Now, let's move on to the next question.

Choice A rationale:

Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action for a client with blood glucose levels ranging from 180 mg/dL to 250 mg/dL following meals. In this scenario, the client's blood glucose levels are already elevated, and increasing carbohydrates may further exacerbate hyperglycemia. It's important to focus on blood glucose control rather than increasing carbohydrate intake.

Choice B rationale:

Scheduling a 2-hour oral glucose tolerance test is not the immediate action required in this case. While this test can help diagnose gestational diabetes, the client's elevated post-meal blood glucose levels are already a concern. The primary concern is addressing and managing these high levels before proceeding with additional testing.

Choice C rationale:

Anticipating an order for insulin administration is the correct action. When a client with gestational diabetes has blood glucose levels consistently above the target range, despite dietary modifications, insulin administration may be necessary to achieve glycemic control. This is a key intervention to prevent complications for both the mother and the baby.

Choice D rationale:

Obtaining an HbA1c is not typically done during pregnancy to assess glucose control, as it reflects the average blood glucose levels over the past 2-3 months. In this case, more immediate monitoring and intervention are required to address the high post-meal blood glucose levels. Now, let's move on to the final question.

Choice A rationale:

Maternal/newborn blood group incompatibility can lead to jaundice in newborns, but it typically occurs within the first 24 hours of life. In this scenario, the baby is delivered 12 hours ago, and the yellowing of the skin is described as "slight.”. Physiologic jaundice, which occurs in the majority of newborns, typically appears on the second or third day after birth, so this choice is less likely.

Choice B rationale:

Physiologic jaundice is the most likely cause of the slight yellowing of the newborn's skin. It typically appears on the second or third day after birth and is related to the immature liver's inability to efficiently process bilirubin. Physiologic jaundice is a common and self-limiting condition that does not usually require treatment.

Choice C rationale:

Maternal cocaine abuse can lead to various neonatal complications, but it is not typically associated with jaundice. The yellowing of the skin in this scenario is more likely related to another cause.

Choice D rationale:

Choice A rationale:

When a pregnant client is Rh negative and the newborn is Rh positive, it can lead to Rh incompatibility issues. This occurs when fetal Rh-positive red blood cells enter the maternal circulation during pregnancy or childbirth, causing the mother's immune system to produce antibodies against Rh-positive blood cells. To prevent Rh sensitization, Rho(D) immune globulin is administered to Rh-negative pregnant clients at specific times during pregnancy and postpartum. This administration is essential to prevent hemolytic disease of the newborn in future pregnancies. The Rho(D) immune globulin prevents the mother's immune system from developing antibodies against Rh-positive blood cells, ensuring that the current pregnancy and future pregnancies remain safe. Therefore, choice A is the correct answer.

Choice B rationale:

If the client is Rh positive and the newborn is Rh positive, there is no need for Rho(D) immune globulin administration. Rh incompatibility issues only occur when the mother is Rh negative, and the newborn is Rh positive. Therefore, choice B is not the correct answer.

Choice C rationale:

When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is unnecessary. This situation is not a reason to administer Rho(D) immune globulin. Choice C is not the correct answer.

Choice D rationale:

If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not required in this scenario. Choice D is not the correct answer.

Choice A rationale:

As mentioned in the previous question, Rho(D) immune globulin should be administered to Rh-negative pregnant clients when the newborn is Rh positive. This is essential to prevent Rh sensitization and hemolytic disease of the newborn in future pregnancies. So, if the client is Rh negative and the newborn is Rh positive, the nurse should administer Rho(D) immune globulin to prevent complications. Choice A is the correct answer.

Choice B rationale:

If both the client and the newborn are Rh positive, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not necessary. Choice B is not the correct answer.

Choice C rationale:

When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is not required. Choice C is not the correct answer.

Choice D rationale:

If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not necessary in this scenario. Choice D is not the correct answer.

Choice C rationale:

The client's blood pressure of 170/101 mm Hg is significantly elevated. This is a systolic blood pressure above 160 mm Hg and a diastolic blood pressure above 110 mm Hg, which is indicative of severe hypertension. Elevated blood pressure during pregnancy can be a sign of preeclampsia, a condition that can have serious consequences for both the mother and the fetus. Therefore, the nurse should report this finding to the provider immediately. Choice C is the correct answer.

Choice D rationale:

Visual disturbances, such as blurred vision, can be an early symptom of preeclampsia. These symptoms, in combination with the elevated blood pressure, are concerning and should be reported to the provider promptly. Visual disturbances can be a sign of central nervous system involvement in preeclampsia. Choice D is the correct answer.

Choice E rationale:

Blood pressure is a vital sign that should be closely monitored during pregnancy. The elevated blood pressure of 170/101 mm Hg is a critical finding and should be reported to the provider immediately. Elevated blood pressure is one of the key diagnostic criteria for preeclampsia. Choice E is the correct answer.

Choice A rationale:

While changes in respiratory rate can be significant, they are not the primary concern in this scenario. The more pressing issues are the elevated blood pressure and visual disturbances, which are strongly indicative of preeclampsia. Choice A is not the most critical finding in this case.

Choice B rationale:

Fetal heart rate (FHR) of 148 is within the normal range for a fetus. FHR monitoring is important, but in this case, the mother's condition and vital signs take precedence due to the potential risks associated with preeclampsia. Choice B is not the most critical finding in this situation.

Choice F rationale:

Deep tendon reflexes are reported as 3+, which can be a sign of hyperreflexia, a neurological symptom associated with preeclampsia. However, the most immediate concerns in this case are the elevated blood pressure, visual disturbances, and signs of preeclampsia. Choice F is not the most critical finding in this context.

Choice A rationale:

The purpose of administering vitamin K to a newborn is to prevent bleeding. Vitamin K plays a crucial role in blood clotting. Newborns often have lower levels of vitamin K, which can make them more susceptible to bleeding disorders, such as hemorrhagic disease of the newborn (HDN). HDN can lead to serious bleeding complications, including intracranial hemorrhage, which can be life-threatening.

Choice B rationale:

Hyperbilirubinemia is not the primary purpose of administering vitamin K. While vitamin K can indirectly help in preventing jaundice (hyperbilirubinemia) by reducing the risk of bleeding that may lead to hemolysis, it is not the primary aim of vitamin K administration.

Choice C rationale:

Potassium deficiency (hypokalemia) is not a primary concern related to vitamin K administration. Vitamin K is specifically administered to prevent bleeding disorders and not to address potassium levels.

Choice D rationale:

Infection is not related to the administration of vitamin K. Vitamin K is not used to prevent or treat infections in newborns; its primary role is in blood clotting.

Choice A rationale:

The rooting reflex is the newborn's natural response to touch around their mouth, particularly the cheek. When the cheek is touched, the infant will turn their head in that direction and open their mouth, initiating the sucking reflex. This reflex helps the newborn find the breast or bottle for feeding.

Choice B rationale:

The Moro reflex is not associated with the initiation of sucking. The Moro reflex is a startle reflex that involves extending and retracting the arms and legs when a newborn feels a sudden loss of support or experiences a loud noise.

Choice C rationale:

The stepping reflex is not related to the initiation of sucking. The stepping reflex is an automatic response that occurs when you hold a newborn upright with their feet touching a surface, causing them to make stepping movements.

Choice D rationale:

The Babinski reflex involves the extension and fanning out of the toes when the sole of the foot is stroked. It is not associated with the initiation of sucking.

Choice A rationale:

Lochia alba, lochia rubra, lochia serosa is not the normal sequence of postpartum vaginal discharge. Lochia rubra is the initial discharge after childbirth, characterized by the presence of red blood and may contain clots. Lochia serosa follows, which is a pinkish or brownish discharge as the bleeding starts to decrease. Lochia alba is the final stage, characterized by a white or yellowish discharge as the body continues to heal.

Choice B rationale:

Lochia serosa, lochia alba, lochia rubra is not the normal sequence of postpartum vaginal discharge. Lochia serosa typically follows lochia rubra, and lochia alba is the final stage.

Choice D rationale:

Lochia rubra, lochia serosa, lochia alba is also not the correct sequence. As mentioned earlier, lochia alba is the final stage of postpartum vaginal discharge. The normal sequence of postpartum vaginal discharge is as follows: Lochia rubra (red), Lochia serosa (pinkish or brownish), and Lochia alba (white or yellowish) as the body heals and recovers from childbirth.

Choice A rationale:

The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.

Choice B rationale:

A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.

Choice C rationale:

A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.

Choice D rationale:

A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.

Choice A rationale:

Cleaning the area around the umbilical cord with baby oil each day is not recommended. The umbilical cord stump should be kept clean and dry to prevent infection. Applying baby oil may create a moist environment, increasing the risk of infection.

Choice B rationale:

Not immersing the newborn's abdomen in water until the cord is dry is the correct instruction. Immersing the newborn's abdomen in water can introduce bacteria to the cord stump, increasing the risk of infection. It is important to keep the cord stump dry and clean until it falls off.

Choice C rationale:

The statement that the stump should fall off in 10 to 14 days is accurate and should be included in the instructions. This timeframe is within the normal range for umbilical cord stump detachment.

Choice D rationale:

Protecting the cord by covering it with the newborn's diaper is not recommended. The cord stump should be left exposed to air to aid in drying and healing. Covering it with a diaper can create a moist environment and increase the risk of infection.

Choice A rationale:

Arranging for counseling to help the client cope with the stress of being a parent is a valid intervention, but it is not the first step in this situation. The client's emotional state may be indicative of postpartum depression, and using a screening tool should be the initial step to assess their condition.

Choice B rationale:

Requesting a prescription for an antidepressant medication is premature without a thorough assessment. Prescribing medication should be based on a formal diagnosis and evaluation of the client's mental health status.

Choice C rationale:

Reinforcing teaching about ways to increase rest and sleep is important for postpartum clients, but it is not the first step in this scenario. The client's emotional well-being and potential postpartum depression need to be addressed initially.

Choice D rationale:

Using a postpartum depression-screening tool with the client is the most appropriate first action. This tool can help assess the client's mental health and identify potential postpartum depression. Once the assessment is completed, appropriate interventions, including counseling or medication, can be recommended as needed. .

Choice A rationale:

February 27, 2023. Naegele's rule is a method used to estimate the expected date of delivery (EDD) based on the first day of the last menstrual period (LMP). To calculate the EDD, you add 280 days (or 9 months) to the LMP date. Choosing February 27, 2023, is incorrect because it is not 9 months after the given LMP date, which was April 4, 2023.

Choice B rationale:

January 11, 2024. This choice is also incorrect. Adding 280 days to the LMP date of April 4, 2023, would give you January 11, 2024. However, Naegele's rule adds 9 months, which should result in an EDD of January 4, 2024. Therefore, this answer is not accurate.

Choice C rationale:

April 4th, 2024. The correct answer is indeed choice C. According to Naegele's rule, you add 280 days to the first day of the last menstrual period. This would result in an EDD of April 4, 2024, making it the most accurate estimate.

Choice D rationale:

April 11, 2023. This choice is incorrect because it does not follow Naegele's rule, which adds 280 days to the LMP date. Choosing April 11, 2023, would only add 7 days to the LMP date and is not an accurate estimation of the EDD.

Choice A rationale:

Gender of the fetus. Amniocentesis is a medical procedure used to sample amniotic fluid surrounding the fetus in the womb. It is primarily performed to obtain information about the fetus's health and development. Determining the gender of the fetus is not a standard indication for amniocentesis.

Choice B rationale:

Weeks of gestation. This is the correct answer. Amniocentesis is often performed to determine the gestational age of the fetus. It helps healthcare providers confirm the number of weeks of gestation and ensure the fetus is at an appropriate developmental stage.

Choice C rationale:

Anatomic abnormalities. Amniocentesis can be used to detect certain chromosomal abnormalities and genetic disorders in the fetus, but it is not primarily performed to identify anatomic abnormalities.

Choice D rationale:

Maturity of lungs. Determining the maturity of the fetus's lungs is typically done using other methods, such as assessing lung function and surfactant levels. It is not the primary purpose of amniocentesis.

Choice A rationale:

"This is a screening tool for spina bifida.”. This statement is incorrect. An ultrasound performed before an amniocentesis is not primarily used as a screening tool for spina bifida. Spina bifida can be detected through other diagnostic tests.

Choice B rationale:

"It is useful for estimating fetal age.”. While ultrasounds can provide information about fetal age, it is not the primary reason for performing an ultrasound before an amniocentesis. The main purpose is to identify the location of the placenta and fetus, which is essential for safely performing the amniocentesis procedure.

Choice C rationale:

"It assists in identifying the location of the placenta and fetus.”. This is the correct answer. An ultrasound before amniocentesis is crucial for locating the fetus and the placenta accurately. This information helps healthcare providers ensure the safe and precise insertion of the needle into the amniotic sac.

Choice D rationale:

"This will determine if there is more than one fetus.”. Determining if there is more than one fetus is an important aspect of prenatal care but is not the primary reason for performing an ultrasound before amniocentesis. It is generally confirmed through earlier ultrasounds during routine prenatal care. .

Choice A rationale:

The client is experiencing symptoms that suggest hyperventilation due to paced breathing, which can lead to respiratory alkalosis. Breathing into a paper bag or cupped hand allows the client to rebreathe carbon dioxide and helps correct the alkalosis by increasing the carbon dioxide levels in the blood. This is a common intervention for clients experiencing lightheadedness and tingling in the fingers due to hyperventilation.

Choice B rationale:

Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate in this situation. It can worsen the client's symptoms and may lead to further hyperventilation. This choice does not address the underlying problem of respiratory alkalosis.

Choice C rationale:

Having the client tuck her chin to her chest is not the correct action for these symptoms. This maneuver is typically used to relieve supraventricular tachycardia (SVT) or vagal stimulation in situations of rapid heart rate. It is not relevant to the client's lightheadedness and tingling fingers.

Choice D rationale:

Administering oxygen via nasal cannula is not indicated in this case. The client's symptoms are not suggestive of hypoxemia, but rather, they are related to respiratory alkalosis. Providing oxygen could potentially worsen the condition by reducing carbon dioxide levels further.