# A primigravida at 41 weeks gestation is admitted for labor induction due to post-term pregnancy. The nurse is preparing to assist with amniocentesis to assess fetal lung maturity. Which nursing action is the highest priority to ensure patient safety during this procedure? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543018 > language: ko > subject: Maternal Newborn Health ## 문제 A primigravida at 41 weeks gestation is admitted for labor induction due to post-term pregnancy. The nurse is preparing to assist with amniocentesis to assess fetal lung maturity. Which nursing action is the highest priority to ensure patient safety during this procedure? ## 보기 1. Position the client in left lateral position to prevent supine hypotension 2. Continuously monitor fetal heart rate before, during, and after the procedure **✔ 정답** 3. Ensure informed consent is obtained and documented in the medical record 4. Administer prophylactic antibiotics as ordered to prevent infection **정답: 2** ## 해설 Continuous fetal heart rate monitoring is highest priority during amniocentesis to immediately detect fetal distress (e.g., bradycardia, decelerations). Other actions (positioning, consent, antibiotics) are important but do not provide real-time fetal safety assessment. ## 심화 해설 Understanding the Priority: Safety During Invasive Procedures When a post-term pregnancy requires amniocentesis for fetal lung maturity assessment, the nurse must prioritize actions that directly protect both the mother and fetus from immediate harm. While all listed options are important, the NCLEX-RN examination tests the ability to distinguish the highest priority action based on the most immediate physiological risk. The correct answer is to continuously monitor fetal heart rate (FHR) before, during, and after the procedure. The primary rationale is the direct risk of procedure-related complications that can cause acute fetal compromise. Amniocentesis involves inserting a needle through the maternal abdomen and uterus into the amniotic cavity. Potential complications include placental abruption, umbilical cord laceration, or fetal bradycardia secondary to vagal stimulation or amniotic fluid embolism. Continuous FHR monitoring provides real-time data on fetal well-being, allowing for immediate detection of non-reassuring patterns and emergency intervention, such as an emergency cesarean section. This aligns with the foundational principle of assessing the most vulnerable patient—the fetus—during an invasive procedure. Analysis of Other Options - Option 1: Position the client in left lateral position. While positioning a term patient in a left lateral tilt is crucial to prevent supine hypotensive syndrome (aortocaval compression by the gravid uterus), this is a preparatory comfort and safety measure, not the highest priority during the procedure itself. The immediate risk of fetal injury from the needle takes precedence over the slower-developing risk of maternal hypotension. - Option 3: Ensure informed consent is obtained and documented. Obtaining informed consent is a critical legal and ethical nursing responsibility before any invasive procedure. However, it is an action that must be completed prior to the procedure's start. During the procedure, the nurse's focus shifts from documentation to physiological surveillance. The NCLEX-RN prioritizes an action in the moment of the procedure over a task that should have already been completed. - Option 4: Administer prophylactic antibiotics. Routine prophylactic antibiotics are not the standard of care for an amniocentesis. The procedure is performed under aseptic technique, and the risk of introducing infection is low if proper skin preparation is used. Administering a medication without a clear, evidence-based indication violates the principle of medication safety. The immediate risk of physical trauma to the fetus far outweighs the minimal infection risk in this scenario. Clinical Reasoning and Test-Taking Strategy This question applies the nursing process and Maslow's hierarchy of needs within a physiological integrity framework. The nurse must first assess for life-threatening complications. Continuous FHR monitoring is the only option that provides ongoing assessment of the fetus's physiological status. A sudden, sustained fetal bradycardia to a rate below 110 bpm would indicate severe fetal distress, demanding immediate cessation of the procedure and emergency intervention. This makes it the priority nursing action to ensure patient safety during the procedure. ## 임상 시나리오 Clinical Practice Guide: Amniocentesis for Fetal Lung Maturity Pre-Procedure Safety Checklist - Verify informed consent is signed and documented before the patient is prepped or sedated. - Confirm patient identity, correct gestational age (41 weeks), and indication for amniocentesis using two identifiers. - Assess for contraindications: active vaginal bleeding, oligohydramnios, or maternal coagulopathy. - Perform a baseline 20-minute electronic fetal monitoring strip to confirm a reassuring fetal heart rate pattern and absence of contractions. - Position the patient with a left lateral tilt using a wedge under the right hip to displace the uterus off the vena cava and prevent supine hypotension. - Prepare ultrasound guidance equipment to determine placental location, fetal position, and a safe needle insertion pocket. Intra-Procedure Monitoring Priorities - Maintain continuous electronic fetal monitoring throughout the needle insertion and fluid aspiration. This is the highest priority nursing action to detect immediate fetal distress. - Observe the fetal heart rate tracing for sudden bradycardia, variable decelerations, or loss of variability, which may indicate cord compression, placental abruption, or fetal vagal response. - Monitor maternal vital signs every 5 minutes, noting any hypotension, tachycardia, or complaints of sharp abdominal pain. - Assist the provider by labeling amniotic fluid samples correctly and transporting them immediately to the lab for L/S ratio or phosphatidylglycerol testing. - Provide emotional support and coaching; instruct the patient to remain still and breathe slowly during needle insertion. Post-Procedure Surveillance - Continue fetal heart rate monitoring for at least 30 minutes after the procedure to confirm a return to baseline and rule out delayed decelerations. - Monitor maternal vital signs and assess for vaginal bleeding, amniotic fluid leakage, or uterine tenderness every 15 minutes for the first hour. - Administer Rh immune globulin (RhoGAM) if the patient is Rh-negative, as fetal-maternal hemorrhage is a risk. - Document the procedure: time, provider, number of attempts, fluid characteristics, FHR response, and patient tolerance. - Report any non-reassuring fetal status or maternal instability immediately to the provider and prepare for possible emergency cesarean delivery. ## 핵심 개념 - **Amniocentesis** — An invasive prenatal diagnostic procedure where a needle is inserted through the maternal abdomen into the amniotic sac to obtain amniotic fluid for testing, carrying risks of placental abruption, cord laceration, or fetal bradycardia. - **Placental Abruption** — Premature separation of the placenta from the uterine wall, a potential complication of amniocentesis that can cause severe maternal hemorrhage and fetal distress. - **Supine Hypotensive Syndrome** — Compression of the inferior vena cava and aorta by the gravid uterus when a pregnant woman lies flat on her back, reducing cardiac output and causing maternal hypotension and fetal hypoxia. - **Fetal Bradycardia** — An abnormally slow fetal heart rate, often defined as less than 110 beats per minute for at least 10 minutes, which can be triggered by vagal stimulation during invasive procedures. ## 같은 주제 문제 - [A primigravida at 41 weeks gestation is admitted for labor induction due to post-term preg…](https://mymerci.kr/pages/nclex_q.php?qn_id=543013) - [A 32-year-old multigravida at 42 weeks gestation is admitted for labor induction due to po…](https://mymerci.kr/pages/nclex_q.php?qn_id=543014) - [A primigravida at 41 weeks gestation is admitted for labor induction due to post-term preg…](https://mymerci.kr/pages/nclex_q.php?qn_id=543015) - [A 25-year-old primigravida at 40 weeks gestation with gestational diabetes is admitted for…](https://mymerci.kr/pages/nclex_q.php?qn_id=543016) - [A nurse is caring for a client at 38 weeks gestation who is undergoing a vacuum-assisted v…](https://mymerci.kr/pages/nclex_q.php?qn_id=543017) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._