Nokea
A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?
- A. This test screens for neural tube defects and other developmental abnormalities in the fetus.
- B. It assesses various markers of fetal well-being.
- C. This test identifies an Rh incompatibility between the mother and fetus.
- D. It is a screening test for spinal defects in the fetus.
Correct Answer: A
Rationale: The correct answer is A because the maternal serum alpha-fetoprotein test is specifically used to screen for neural tube defects and other developmental abnormalities in the fetus. Alpha-fetoprotein levels in the mother's blood can indicate the presence of such abnormalities. This test is typically done around 15-20 weeks of gestation.
Choice B is incorrect because the maternal serum alpha-fetoprotein test is not used to assess various markers of fetal well-being. Choice C is incorrect because it does not identify Rh incompatibility, which is typically detected through other tests. Choice D is incorrect because the test is not primarily for spinal defects, but rather for neural tube defects and other developmental abnormalities.
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A parent of a newborn is being taught about crib safety. Which statement by the client indicates understanding of the teaching?
- A. I will place my baby on his stomach when he is sleeping.
- B. I should remove extra blankets from my baby's crib.
- C. I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps.
- D. I should place my baby's crib next to the heater to keep him warm during the winter.
Correct Answer: B
Rationale: The correct answer is B because removing extra blankets from the baby's crib reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby on the stomach (Option A) increases the risk of SIDS. Padding the mattress (Option C) can also increase the risk of suffocation. Placing the crib next to a heater (Option D) can lead to overheating and poses a fire hazard. Removing extra blankets ensures a safe sleep environment for the baby.
After an amniotomy, what is the priority nursing action?
- A. Observe color and consistency of fluid
- B. Assess the fetal heart rate pattern
- C. Assess the client's temperature
- D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation
Correct Answer: B
Rationale: The correct answer is B: Assess the fetal heart rate pattern. After an amniotomy (breaking of the water), the priority is to monitor the fetal well-being to ensure the baby is tolerating the procedure well. Assessing the fetal heart rate pattern helps the nurse determine if the baby is experiencing any distress or changes in oxygenation. This immediate assessment is crucial in identifying any potential complications and taking prompt action.
Observing the color and consistency of fluid (A) is important but not as immediate as assessing the fetal heart rate. Assessing the client's temperature (C) and evaluating for chills and increased uterine tenderness (D) are important but do not address the immediate concern of fetal well-being post-amniotomy.
While caring for a newborn, a nurse auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Ask another nurse to verify the heart rate.
- B. Document this as an expected finding.
- C. Call the provider to further assess the newborn.
- D. Prepare the newborn for transport to the NICU.
Correct Answer: B
Rationale: The correct answer is B: Document this as an expected finding. A heart rate of 130/min in a newborn is within the normal range (120-160/min). The nurse should document this as an expected finding because it indicates a healthy heart rate for a newborn. There is no immediate need for intervention or further assessment as the heart rate falls within the normal range for a newborn. Asking another nurse to verify the heart rate (choice A) is unnecessary as it is within the normal range. Calling the provider to further assess the newborn (choice C) is not needed since the heart rate is normal. Preparing the newborn for transport to the NICU (choice D) is not indicated as the heart rate is within the normal range.
A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?
- A. On days 13 to 17 of her menstrual cycle
- B. Every morning before arising
- C. 1 hour following intercourse
- D. Before going to bed every night
Correct Answer: B
Rationale: The correct answer is B: Every morning before arising. This is because basal body temperature is the lowest body temperature attained during rest, typically just before waking up. Checking the temperature at this time provides the most accurate measurement of basal temperature. Options A, C, and D are incorrect because ovulation typically occurs around 14 days before the start of the next menstrual period, not on days 13 to 17 specifically (A), 1 hour following intercourse is not a reliable indicator of ovulation (C), and basal temperature should be checked in the morning, not before going to bed at night (D).
A client is being educated by a healthcare provider about the changes she should expect when planning to become pregnant. Identify the correct sequence of maternal changes. A. Amenorrhea B.Lightening C. Goodell's sign D. Quickening
- A. A,B,C,D
- B. D,B,A,C
- C. A,D,B,C
- D. A,C,D,B
Correct Answer: D
Rationale: The correct sequence of maternal changes when planning to become pregnant is A) Amenorrhea, C) Goodell's sign, D) Quickening, and B) Lightening. Amenorrhea is the absence of menstruation, indicating possible pregnancy. Goodell's sign is the softening of the cervix and vagina. Quickening is the first fetal movements felt by the mother. Lightening occurs as the baby drops lower into the pelvis. This sequence reflects the chronological order of physiological changes during pregnancy. Choices A, B, and C do not follow the correct sequence of maternal changes as outlined in pregnancy progression.