Nokea
A 36-week-gestation client is having an amniocentesis. For which of the following reasons is the test likely being conducted?
- A. Genetic evaluation.
- B. Assessment of intrauterine growth restriction.
- C. Assessment of fetal lung maturation.
- D. Hormonal studies.
Correct Answer: C
Rationale: Amniocentesis at 36 weeks is often performed to assess fetal lung maturity before delivery.
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When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: The correct answer is C: 10 weeks. CVS is typically performed between 10-12 weeks of gestation. At this time, there is enough fetal tissue for sampling without significant risk to the pregnancy. Performing CVS earlier (options A, B) may result in insufficient tissue for accurate testing, while performing it later (option D) may increase the risk of procedure-related complications. Option C provides the optimal balance between ensuring accurate results and minimizing potential risks to the pregnancy.
A nurse has just received report on 4 neonates in the newborn nursery. Which of the babies should the nurse assess first?
- A. Neonate whose mother is HIV positive.
- B. Neonate whose mother is group B streptococcus positive.
- C. Neonate whose mother’s labor was 12 hours long.
- D. Neonate whose mother gained 45 pounds during her pregnancy.
Correct Answer: B
Rationale: The neonate whose mother is group B streptococcus positive should be assessed first due to the risk of early-onset sepsis.
An NST is performed on a client who is G6T3P1A1L4 38 weeks gestation. After the patient has been on the external monitor for 30 minutes, the nurse sees three fetal heart rate accelerations of 15 bpm lasting 5 seconds in association with fetal movement. The nurse documents this finding as which of the following?
- A. Unsatisfactory
- B. A reactive NST
- C. A nonreactive nonstress test
- D. Equivocal suspicious
Correct Answer: B
Rationale: The correct answer is B: A reactive NST. This is because the NST shows three fetal heart rate accelerations of 15 bpm lasting 5 seconds each, in association with fetal movement. A reactive NST indicates a normal response, which is characterized by the presence of fetal heart rate accelerations associated with fetal movement. This is a reassuring finding, suggesting fetal well-being.
Choice A (Unsatisfactory) is incorrect because the description of the findings indicates a satisfactory response. Choice C (A nonreactive nonstress test) is incorrect because the test showed accelerations in response to fetal movements, which is not consistent with a nonreactive test. Choice D (Equivocal suspicious) is incorrect as there is no indication of uncertainty or suspicion in the findings described.
When should the nurse begin discharge planning?
- A. When the patient is ready
- B. Close to the time of discharge
- C. Upon admission to the hospital
- D. After an order is written/prescribed
Correct Answer: C
Rationale: Discharge planning begins the moment a patient is admitted to a health care facility.
A nurse is completing a minimum data set. Which area is the nurse working?
- A. Nursing center
- B. Psychiatric facility
- C. Rehabilitation center
- D. Adult day care center
Correct Answer: A
Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.