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A pregnant patient has received the results of her triple-screen testing and it is positive. What would the nurse anticipate as the next step in the patient’s plan of care?
- A. No further testing is indicated at this time because results are normal.
- B. Refer to the physician for additional testing.
- C. Validate the results with the lab facility.
- D. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.
Correct Answer: B
Rationale: A positive triple-screen test suggests an increased risk of genetic abnormalities, requiring additional diagnostic testing.
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Which of the following exercises should be taught to a pregnant woman who complains of backaches?
- A. Kegeling.
- B. Pelvic tilting.
- C. Leg lifting.
- D. Crunching.
Correct Answer: B
Rationale: Pelvic tilting exercises help to alleviate backaches by strengthening the abdominal and lower back muscles. Kegeling, leg lifting, and crunching are not specifically targeted at relieving backaches.
A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse’s most appropriate response?
- A. The test results are within normal limits.
- B. Immediate birth by cesarean birth is being considered.
- C. Further testing will be performed to determine the meaning of this score.
- D. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.
Correct Answer: A
Rationale: A score of 8-10 is within the normal range for a biophysical profile, indicating no immediate concerns for the fetus.
A nurse is preparing a laboring person for an epidural. What is the most important nursing intervention before the procedure?
- A. Ensure informed consent is signed
- B. Administer IV fluids
- C. Monitor maternal vital signs
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Ensure informed consent is signed. Before any procedure, it is crucial to obtain informed consent to ensure the individual understands the risks, benefits, and alternatives. This protects their autonomy and ensures they are making an informed decision. Administering IV fluids (B) is important but not as critical as obtaining consent. Monitoring vital signs (C) is essential but not the most important step before the procedure. Administering pain relief (D) should only be done after ensuring informed consent and assessing the individual's pain level.
A nurse is caring for a postpartum person who is experiencing excessive bleeding. What should the nurse assess first?
- A. perform uterine massage
- B. perform a vaginal examination
- C. evaluate blood loss
- D. perform a uterine check
Correct Answer: A
Rationale: The correct answer is A: perform uterine massage. This is the priority because uterine massage helps to stimulate uterine contractions, which can help control bleeding in postpartum individuals. It is crucial to address the source of bleeding first. Performing a vaginal examination (choice B) may exacerbate bleeding. Evaluating blood loss (choice C) is important but not the initial step. Performing a uterine check (choice D) is vague and not as specific as uterine massage in addressing postpartum bleeding.
What is the primary purpose of a non-stress test (NST) during pregnancy?
- A. to assess fetal heart rate variability
- B. to evaluate fetal well-being
- C. to assess fetal heart rate accelerations
- D. to assess maternal well-being
Correct Answer: C
Rationale: The correct answer is C: to assess fetal heart rate accelerations. An NST is used to monitor the baby's heart rate and movement to ensure adequate oxygen supply. Fetal heart rate accelerations indicate a healthy, responsive baby. Assessing heart rate variability (A) is important but not the primary purpose. Evaluating fetal well-being (B) is broad and doesn't capture the specific focus on heart rate accelerations. Assessing maternal well-being (D) is not the purpose of an NST.