Nokea
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
- A. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results.
- B. Maintain NPO status prior to testing.
- C. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
- D. Have an infusion pump prepared with oxytocin per protocol for evaluation.
Correct Answer: C
Rationale: The correct answer is C because positioning the patient for comfort and adjusting the tocotransducer belt to locate fetal heart rate are essential steps in preparing a pregnant patient for a nonstress test (NST). This allows for proper monitoring of fetal heart rate without interference.
A: Having the patient void prior to the test is not necessary for an NST as a full bladder does not interfere with the results.
B: Maintaining NPO status is not required for an NST, as it does not involve any invasive procedures that would necessitate fasting.
D: Preparing an infusion pump with oxytocin is not part of the standard preparation for an NST and is not needed for evaluation.
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A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a nutritious diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate in the hallways every shift.
Correct Answer: C
Rationale: Ensuring the client has a moderate lochial flow is a priority to monitor for postpartum hemorrhage.
A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception is
- A. using increased environmental stimulation as a method of distraction.
- B. restricting family and friends from visiting during the labor period to keep the patient focused on breathing techniques.
- C. medicating the patient frequently to reduce pain perception.
- D. assisting the patient in breathing methods aimed at taking control of pain perception based on the contraction pattern.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Breathing techniques help in managing pain perception during labor.
2. By assisting the patient in breathing methods, she gains control over her pain perception.
3. Controlled breathing can help distract from the intensity of contractions.
4. By focusing on breathing patterns, the patient can stay calm and manage pain effectively.
Summary:
A, B, and C are incorrect because they do not address pain management directly through breathing techniques. Option A relies on distraction, B focuses on isolation rather than coping mechanisms, and C suggests heavy reliance on medication rather than self-control.
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?
- A. Hemophilia
- B. Sickle cell anemia
- C. A neural tube defect
- D. Abnormal lecithin-to-sphingomyelin ratio
Correct Answer: C
Rationale: The correct answer is C: A neural tube defect. Elevated AFP levels in maternal serum are indicative of neural tube defects in the fetus. AFP is produced by the fetal liver and yolk sac, and high levels may suggest a defect in the development of the neural tube. Hemophilia (A), sickle cell anemia (B), and abnormal lecithin-to-sphingomyelin ratio (D) do not directly correlate with AFP levels. Hemophilia is a genetic blood disorder, sickle cell anemia is a genetic blood disorder affecting hemoglobin, and abnormal lecithin-to-sphingomyelin ratio is related to fetal lung maturity.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks' gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: The correct answer is B. An L/S ratio of 2:1 is indicative of fetal lung maturity. This means that the lungs of the fetus are likely mature enough to function outside the womb. In choice B, the patient is 24 years old with diabetes, a condition that can affect fetal lung development, making it crucial to assess lung maturity.
Choice A is less likely to have abnormal lung maturity at 38 weeks' gestation. Choice C, a 44-year-old gravida 6, para 5, is more likely to have mature fetal lungs due to multiple pregnancies. Choice D, an 18-year-old in early labor at term, may not necessarily have abnormal lung maturity as she is at term and in labor.
The nurse has admitted a client who is 30 weeks gestation with suspected intrauterine growth restriction. The physician has ordered a Doppler blood flow study. What does the nurse suspect if the results show an S/D ratio above the 95th percentile for the gestational age, a ratio above 3, or end-diastolic blood flow that is absent or reversed?
- A. Decreased blood pressure
- B. Placental insufficiency
- C. Increased amniotic fluid
- D. Decreased fetal movement
Correct Answer: B
Rationale: The correct answer is B: Placental insufficiency. An elevated S/D ratio (>95th percentile for gestational age or >3) and absent/reversed end-diastolic blood flow on Doppler study indicate impaired placental blood flow, leading to decreased oxygen and nutrient delivery to the fetus. This can result in intrauterine growth restriction (IUGR) and compromise fetal well-being. Decreased blood pressure (A) is not directly related to these Doppler findings. Increased amniotic fluid (C) is more commonly associated with conditions like fetal anomalies or maternal diabetes. Decreased fetal movement (D) may be a sign of fetal distress but is not specifically indicated by Doppler findings in IUGR.