Nokea
16wks gestation reports for a triple screen test. What statements determines understanding?
- A. "This test can be used as a screening for spina bifida."
- B. "This test is a screen test, and I will need other testing if I have abn results."
- C. "this test can indicate if I may be at an increased risk for having a child with down syndrome."
- D. A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, hcg, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomy's. Spina bifida and downs syndrome are the two most common risks.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels.
2. These values help determine the risk for neural tube defects and chromosomal trisomies.
3. The test does not directly diagnose spina bifida but assesses neural tube defects.
4. Down syndrome risk is also evaluated, not diagnosed directly.
5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function.
Summary of why other choices are incorrect:
A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida.
B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test.
C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.
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The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.
As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
A patient vaginally delivered an infant at 4750 g moderate shoulder dystocia occurred during the birth. During the initial assessment of the infant the nurse should look for
- A. Erb's palsy
- B. Bell palsy
- C. Bradycardia
- D. Petechiae
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. During shoulder dystocia, the infant may experience umbilical cord compression leading to decreased oxygen supply and potential bradycardia. Bradycardia is a critical sign that requires immediate attention. Erb's palsy (A) is a brachial plexus injury due to shoulder dystocia, not an immediate concern. Bell palsy (B) is a facial nerve paralysis unrelated to birth trauma. Petechiae (D) are small red or purple spots that may indicate bleeding disorders but are not specific to shoulder dystocia.
A client at 37 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Preeclampsia.
- B. Cholestasis of pregnancy.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: B
Rationale: The correct answer is B: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 37 weeks' gestation is concerning for cholestasis of pregnancy, a condition characterized by impaired bile flow. This can lead to elevated bile acids, causing itching. Preeclampsia (choice A) presents with hypertension and proteinuria. Gestational diabetes (choice C) manifests with high blood sugar levels. Fungal infection (choice D) typically presents with visible skin changes like a rash, which is absent in this case. In summary, cholestasis of pregnancy is the most likely explanation for severe itching in this scenario.
A nurse is reviewing the laboratory results for a client who is at 29 weeks.... the provider?
- A. WBC count
- B. 11,000/mm³ Hgb
- C. 11,2 g/Dl
- D. Hct 34% Platelets 140,000/mm³
Correct Answer: B
Rationale: The correct answer is B: 11,000/mm³ Hgb. At 29 weeks of gestation, hemoglobin (Hgb) levels are crucial to monitor for anemia in pregnant women. A Hgb level of 11,000/mm³ is within the normal range for a pregnant woman. Anemia during pregnancy can lead to adverse outcomes for both the mother and the baby, such as preterm birth and low birth weight.
Rationale for other choices:
A: WBC count - While monitoring white blood cell (WBC) counts is important for detecting infections, it is not the most relevant parameter to review in this scenario.
C: 11,2 g/Dl - This choice is incomplete and doesn't provide a specific parameter or context for interpretation.
D: Hct 34% Platelets 140,000/mm³ - Hematocrit (Hct) and platelet levels are important, but in this case, the Hgb level is more pertinent