Nokea
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
- A. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
- B. Discuss options for intrauterine surgical correction of congenital defects.
- C. Reassure the client that the AFP results are likely to be a false reading.
- D. Explain that a sonogram should be scheduled for definitive results.
Correct Answer: D
Rationale: An elevated alpha-fetoprotein (AFP) level in a pregnant client can indicate potential congenital anomalies in the fetus. A follow-up sonogram is necessary to provide definitive results and further evaluate the fetus for any possible abnormalities. Therefore, it is essential for the nurse to explain to the client that scheduling a sonogram is the next appropriate step to assess the fetal well-being and address any concerns regarding the elevated AFP level. Choices A, B, and C are incorrect because a repeat AFP test alone, discussing surgical correction of defects, or assuming the results are false without further evaluation are not appropriate responses when dealing with a potentially serious issue like elevated AFP levels in pregnancy.
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Using N¤gele's rule, what is the estimated date of delivery for a pregnant client who reports that the first day of her last menstrual period was August 2, 2006?
- A. April 25, 2007.
- B. May 9, 2007.
- C. May 29, 2007.
- D. June 2, 2007.
Correct Answer: B
Rationale: N¤gele's rule is used to estimate the date of delivery. It involves adding 7 days to the first day of the last menstrual period (August 2), which gives August 9. Then, subtracting 3 months from August 9, we arrive at May 9 of the following year as the estimated date of delivery. This makes choice B, 'May 9, 2007,' the correct answer. Choices A, C, and D are incorrect as they do not follow the correct calculation based on N¤gele's rule.
Which intervention is most helpful in relieving postpartum uterine contractions or 'afterpains'?
- A. Lying prone with a pillow on the abdomen.
- B. Using a breast pump.
- C. Massaging the abdomen.
- D. Giving oxytocic medications.
Correct Answer: A
Rationale: Lying prone with a pillow on the abdomen is the most helpful intervention in relieving postpartum uterine contractions or 'afterpains.' This position provides counter-pressure and support to the uterus, helping to alleviate discomfort and promote uterine involution. Choice B, using a breast pump, is not effective in relieving afterpains as it focuses on milk expression. Massaging the abdomen (Choice C) may help with discomfort but does not provide the same level of support as lying prone with a pillow. Giving oxytocic medications (Choice D) is not typically the first-line intervention for afterpains unless there are specific medical indications.
The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer's Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump?
- A. 12 mL/hour
- B. 2 mL/hour
- C. 22 mL/hour
- D. 42 mL/hour
Correct Answer: A
Rationale: To calculate the infusion rate in mL/hour, first, convert 2 milliunits/minute to milliunits/hour by multiplying by 60 to get 120 milliunits/hour. Then, calculate the mL/hour using the formula: milliunits/hour (120) total volume (1000 mL) · units in IV solution (10 units) = 1200 mL/hour. Therefore, the nurse should program the infusion pump to deliver 12 mL/hour to provide the prescribed dose of oxytocin. Choice B is incorrect as it does not reflect the correct calculation. Choice C is incorrect as it is not derived from the correct formula. Choice D is incorrect as it is not the result of the accurate calculation based on the provided information.
To confirm respiratory distress syndrome (RDS) in a newborn, what should the nurse assess?
- A. Assess diaphragmatic breathing.
- B. Assess heart sounds.
- C. Monitor blood oxygen levels.
- D. Check for signs of infection.
Correct Answer: A
Rationale: To confirm respiratory distress syndrome (RDS) in a newborn, the nurse should assess diaphragmatic breathing. In RDS, the baby may have difficulty breathing due to immature lungs, leading to shallow, rapid breathing movements. Assessing diaphragmatic breathing directly evaluates the respiratory effort and can help identify the presence of RDS. Choice B, assessing heart sounds, is not specific to diagnosing RDS but could be relevant for other conditions. Choice C, monitoring blood oxygen levels, is important but alone may not confirm RDS. Choice D, checking for signs of infection, is not a direct indicator of RDS but rather suggests a different issue.
The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
- A. Insert an internal fetal monitor.
- B. Assess for cervical changes q1h.
- C. Monitor bleeding from IV sites.
- D. Perform Leopold's maneuvers.
Correct Answer: C
Rationale: Monitoring for bleeding from IV sites is the priority intervention in this situation. The dark red vaginal bleeding, uterine tension, and other assessment findings suggest a potential placental abruption. Monitoring bleeding from IV sites can help detect coagulopathy, which may be associated with placental abruption. Options A, B, and D are not the most appropriate interventions in this scenario. Inserting an internal fetal monitor, assessing for cervical changes, and performing Leopold's maneuvers are not the priority actions when dark red vaginal bleeding and uterine tension are present, indicating a potential emergency situation.