Nokea
A client at 16 weeks' gestation asks about the purpose of a maternal serum alpha-fetoprotein (MSAFP) test. What is the nurse's best response?
- A. It screens for chromosomal abnormalities.
- B. It detects neural tube defects.
- C. It confirms the gestational age of the baby.
- D. It identifies the baby's sex.
Correct Answer: B
Rationale: The MSAFP test is used to screen for neural tube defects such as spina bifida.
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When evaluating cervical mucus, what is the quality of spinnbarkeit?
- A. elasticity
- B. amount
- C. clarity
- D. color
Correct Answer: A
Rationale: The quality of spinnbarkeit refers to the elasticity of cervical mucus. Spinnbarkeit is a term used to describe the stretchability or stretchy quality of cervical mucus during ovulation. This elasticity is an important characteristic as it indicates the fertile window for a woman trying to conceive. High levels of spinnbarkeit allow for easier passage and survival of sperm, increasing the chances of conception. The other choices (B. amount, C. clarity, D. color) do not specifically refer to the stretchability or elasticity of cervical mucus, which is what is assessed when evaluating spinnbarkeit.
A client in labor is receiving an epidural for pain relief. What is the nurse's priority assessment immediately after the procedure?
- A. Monitor maternal blood pressure.
- B. Assess fetal heart rate.
- C. Check for bladder distention.
- D. Evaluate the client's pain level.
Correct Answer: A
Rationale: Monitoring maternal blood pressure is essential to detect and manage hypotension, a common side effect of epidurals.
A client has just given birth, during labor the fetus was in brow presentation, but after prolonged laboring the fetus convert to occiput presentation and was delivered vaginally by vacuum extraction
- A. What should be explained
- B. Molding of the head will subside in a few days
- C. Meconium aspiration
- D. Infant will have prophylactic antibiotic
Correct Answer: A
Rationale: In this scenario, it is important to explain to the client what happened during labor and delivery. It is essential to communicate that the fetus was in a brow presentation initially, which can sometimes lead to complications during labor. However, the fetus converted to occiput presentation and was successfully delivered vaginally with the help of vacuum extraction. Providing this information to the client helps in ensuring transparency and understanding of the events that occurred, addressing any concerns or questions they may have about the delivery process.
The nurse is educating a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions relieved by rest.
- B. Contractions felt only in the abdomen.
- C. Contractions that increase in intensity and cause cervical changes.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by contractions that progressively increase in intensity and result in cervical dilation and effacement.
The nurse is caring for a client with severe preeclampsia. What finding would indicate magnesium sulfate toxicity?
- A. Increased deep tendon reflexes.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 160/110 mmHg.
Correct Answer: B
Rationale: Respiratory depression is a key sign of magnesium sulfate toxicity, requiring immediate action.