Nokea
A client at 12 weeks' gestation asks about the purpose of nuchal translucency testing. What is the nurse's best response?
- A. It screens for fetal anemia.
- B. It detects neural tube defects.
- C. It screens for chromosomal abnormalities.
- D. It confirms gestational age.
Correct Answer: C
Rationale: The correct answer is C because nuchal translucency testing is primarily used to screen for chromosomal abnormalities, such as Down syndrome, in the fetus. This test measures the thickness of the fluid-filled space at the back of the baby's neck. It is typically done between 11 and 14 weeks of pregnancy. This testing helps to assess the risk of genetic conditions in the fetus. Option A is incorrect because nuchal translucency testing does not screen for fetal anemia. Option B is incorrect because it does not detect neural tube defects. Option D is incorrect because it does not confirm gestational age.
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A client is admitted with a vaginal bleeding at 10 weeks' gestation and her fundal height 13cm. Which potential problem should you investigate?
- A. Hydatidiform mole
- B. DIC
- C. Previa
- D. Abruptio placenta
Correct Answer: C
Rationale: The correct answer is C: Previa. At 10 weeks' gestation, fundal height should be close to the pelvic brim, not 13cm above it. This suggests placenta previa, where the placenta implants low in the uterus, causing bleeding. Hydatidiform mole would typically present with earlier bleeding and a larger uterus. DIC and abruptio placenta are not supported by the information given at this gestational age.
Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)
- A. Continuing to deny the pregnancy
- B. Uncertainty about where to go for care
- C. Lack of realization that they are pregnant
- D. A desire to gain control over their situation
Correct Answer: A
Rationale: The correct answer is A: Continuing to deny the pregnancy. This is because some teens may struggle to come to terms with their pregnancy and deny it, leading to delays in seeking prenatal care. The other choices are incorrect. B: Uncertainty about where to go for care is not a common reason for delaying prenatal care as resources and information are usually available. C: Lack of realization that they are pregnant is unlikely as most teens eventually become aware of their pregnancy. D: A desire to gain control over their situation does not usually lead to delaying prenatal care as seeking care is a proactive step towards gaining control.
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
- A. "It sounds like you are feeling sad that things didn't go as planned."
- B. "At least you know you have a healthy baby."
- C. "Maybe next time you can have a vaginal delivery."
- D. "You can resume sexual relations sooner than if you had delivered vaginally."
Correct Answer: A
Rationale: Step 1: Empathy - The nurse acknowledges the client's feelings of disappointment, showing empathy and understanding.
Step 2: Validation - By stating "It sounds like you are feeling sad that things didn't go as planned," the nurse validates the client's emotions, making her feel heard and supported.
Step 3: Therapeutic Communication - This response encourages the client to express her feelings further, promoting open communication and trust in the nurse-client relationship.
Summary:
Choice B is incorrect as it dismisses the client's emotional concerns and focuses solely on the baby's health. Choice C is incorrect as it minimizes the client's current experience and may increase feelings of inadequacy. Choice D is incorrect as it is not relevant to the client's emotional needs and may be perceived as insensitive.
A client at 20 weeks' gestation reports leg cramps. What recommendation should the nurse provide?
- A. Increase potassium intake.
- B. Stretch the legs before bed.
- C. Drink fluids during meals.
- D. Reduce physical activity.
Correct Answer: B
Rationale: The correct answer is B: Stretch the legs before bed. Leg cramps during pregnancy are common due to increased weight and pressure on blood vessels. Stretching before bed helps prevent cramps by improving circulation and muscle relaxation. Increasing potassium intake (choice A) can help with muscle function but is not the primary intervention for leg cramps. Drinking fluids during meals (choice C) is important for hydration but does not directly address leg cramps. Reducing physical activity (choice D) may worsen circulation and muscle cramps.
The nurse is preparing a client for induction of labor. What is the purpose of administering oxytocin?
- A. Stimulate uterine contractions.
- B. Relieve pain during labor.
- C. Promote cervical ripening.
- D. Reduce maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Stimulate uterine contractions. Oxytocin is administered to induce labor by increasing the frequency and strength of uterine contractions. This helps progress labor and facilitate delivery. Choice B is incorrect as pain relief is usually achieved through analgesics or anesthesia. Choice C is incorrect because cervical ripening is typically promoted with medications like prostaglandins. Choice D is also incorrect as oxytocin can actually cause a temporary increase in blood pressure.