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. Discuss options for intrauterine surgical correction of congenital defects.
- B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
- 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 AFP level is a screening indicator, not a diagnosis. A sonogram is the next step to assess for neural tube defects or other anomalies, providing definitive information.
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The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?
- A. Obtain blood and urine for prenatal screens
- B. Explain common complications of pregnancy
- C. Obtain baseline blood pressure and weight
- D. Schedule prenatal visits to occur monthly
Correct Answer: A
Rationale: Given the history of syphilis, obtaining blood and urine for prenatal screens is critical to assess for active infection or other risks that could impact the pregnancy.
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?
- A. Chromosomal abnormalities
- B. Sex and size of the infant
- C. Lecithin-sphingomyelin ratio
- D. Fetal growth and gestational age.
Correct Answer: D
Rationale: A routine ultrasound at 20 weeks primarily assesses fetal growth and gestational age to ensure proper development.
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to
- A. dilate the pupil so the red reflex can be visualized
- B. prevent herpes infection.
- C. prevent eye infections
- D. clear the infant's vision
Correct Answer: C
Rationale: Antibiotic eye ointment, typically erythromycin, is applied to prevent neonatal conjunctivitis, particularly from gonorrhea or chlamydia, which can be transmitted during birth.
The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Cries vigorously when stimulated
- B. A positive Babinski reflex
- C. Heart rate of 220 beats/minute
- D. Flexion of all four extremities
Correct Answer: A
Rationale: Vigorous crying indicates effective breathing and responsiveness, key signs of successful transition to extrauterine life.