Nokea
During preterm labor, a client is scheduled for an amniocentesis. The nurse should review which of the following tests to assess fetal lung maturity?
- A. Alpha-fetoprotein (AFP)
- B. Lecithin/sphingomyelin (L/S) ratio
- C. Kleihauer-Betke test
- D. Indirect Coombs' test
Correct Answer: B
Rationale: The correct answer is B: Lecithin/sphingomyelin (L/S) ratio. This test is used to assess fetal lung maturity by determining the ratio of two substances present in amniotic fluid. An L/S ratio of 2:1 or higher indicates mature fetal lungs, reducing the risk of respiratory distress syndrome in preterm infants.
A: Alpha-fetoprotein (AFP) is used to screen for neural tube defects, not fetal lung maturity.
C: Kleihauer-Betke test is used to detect fetal-maternal hemorrhage.
D: Indirect Coombs' test is used to detect antibodies in maternal blood that may attack fetal red blood cells, not assess fetal lung maturity.
In summary, the L/S ratio test is the most appropriate choice to assess fetal lung maturity during preterm labor, as it directly correlates with the development of the fetal lungs.
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A healthcare provider is instructing a client who is taking an oral contraceptive about manifestations to report. Which of the following manifestations should the healthcare provider include?
- A. Reduced menstrual flow
- B. Breast tenderness
- C. Shortness of breath
- D. Increased appetite
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath. This is because shortness of breath can indicate a potentially serious side effect like a blood clot, which is a rare but serious complication associated with oral contraceptives. Reduced menstrual flow (A) is a common side effect and not typically a cause for concern. Breast tenderness (B) is a common but generally benign side effect of oral contraceptives. Increased appetite (D) is also a common side effect but not typically a sign of a serious complication. Therefore, the healthcare provider should emphasize the importance of reporting shortness of breath promptly.
During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?
- A. Leukorrhea
- B. Supine hypotension
- C. Periodic numbness of the fingers
- D. Decreased urine output
Correct Answer: D
Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.
When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?
- A. I am glad I can have my morning coffee.
- B. I should take folic acid to increase my milk supply.
- C. I will continue adding 330 calories per day to my diet.
- D. I will continue my calcium supplements because I don't like milk.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates an understanding of the importance of calcium intake for breastfeeding mothers. Calcium is essential for both the mother's health and the baby's bone development. Continuing calcium supplements shows a commitment to meeting nutritional needs.
Incorrect choices:
A: Having coffee is fine, but it's not directly related to postpartum nutrition needs.
B: Folic acid is important for pregnancy but not specifically for increasing milk supply.
C: While additional calories are needed during breastfeeding, the specific amount varies and is not always 330 calories per day.
During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?
- A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
- B. A fourth-degree episiotomy extends into the rectal area and is not recommended
- C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
- D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries
Correct Answer: C
Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure.
A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client.
B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter.
D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.
A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?
- A. Active
- B. Transition
- C. Latent
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase.
Summary:
A: Active phase occurs when the cervix is dilated from 4 to 7 cm.
C: Latent phase occurs when the cervix is dilated from 0 to 3 cm.
D: Descent phase is not a recognized phase of labor.