Nokea
The nurse is caring for a client being monitored for oligohydramnios. The NST is nonreactive. Which findings correlate with these results?
- A. Less than 2 accelerations in 20 to 40 minutes
- B. Accelerations of at least 15 bpm lasting at least 15 seconds (more than 32 weeks gestation)
- C. Accelerations of at least 10 bpm lasting at least 10 seconds (less than 32 weeks gestation)
- D. Four accelerations in 20 to 40 minutes
Correct Answer: A
Rationale: Step 1: Oligohydramnios indicates decreased amniotic fluid, which can lead to fetal hypoxia.
Step 2: Nonreactive NST suggests lack of appropriate fetal heart rate accelerations in response to fetal movement.
Step 3: Less than 2 accelerations in 20-40 minutes is consistent with nonreactive NST due to decreased fetal movement.
Step 4: Choice A is correct as it reflects the expected findings in a nonreactive NST scenario.
Summary:
- Choice B: The criteria for accelerations are too high for a nonreactive NST.
- Choice C: The criteria for accelerations are too low for a nonreactive NST.
- Choice D: Four accelerations in the given time frame do not correlate with a nonreactive NST.
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A 36-week-gestation client is having an amniocentesis. For which of the following reasons is the test likely being conducted?
- A. Genetic evaluation.
- B. Assessment of intrauterine growth restriction.
- C. Assessment of fetal lung maturation.
- D. Hormonal studies.
Correct Answer: C
Rationale: Amniocentesis at 36 weeks is often performed to assess fetal lung maturity before delivery.
A patient with an IUD in place has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action?
- A. A therapeutic abortion will need to be scheduled since fetal damage is inevitable.
- B. Hormonal analyses will be done to determine the underlying cause of the false-positive test result.
- C. The IUD will need to be removed to avoid complications such as miscarriage or infection.
- D. The IUD will need to remain in place to avoid injuring the fetus.
Correct Answer: C
Rationale: Rationale:
C is correct because when a patient with an IUD in place has a positive pregnancy test, the IUD should be removed to avoid complications such as ectopic pregnancy, miscarriage, or infection. Leaving the IUD in place can increase the risk of adverse outcomes for both the mother and the fetus. Removing the IUD allows for safer management of the pregnancy and reduces potential harm.
Summary:
A: Incorrect. Fetal damage is not inevitable, and a therapeutic abortion is not the immediate action required in this situation.
B: Incorrect. Hormonal analyses are not the priority when a positive pregnancy test with an IUD in place is detected.
D: Incorrect. Leaving the IUD in place can lead to complications and is not the recommended course of action.
A biophysical profile is performed on a pregnant patient. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. Which answer would be the correct interpretation of this test result?
- A. A score of 10 would indicate that the results are equivocal.
- B. A score of 8 would indicate normal results.
- C. A score of 6 would indicate that birth should be considered as a possible treatment option.
- D. A score of 9 would indicate reassurance.
Correct Answer: B
Rationale: The correct answer is B: A score of 8 would indicate normal results. In a biophysical profile, each component is scored as either 0 or 2, totaling a maximum of 10. In this case, the patient has: 0 for NST, 2 for FBMs, 1 for gross movements, 2 for fetal tone, and 2 for AFI, totaling 7. However, if there are at least 2 episodes of FBMs, this component is given a score of 2. Therefore, the correct total score is 8. This score indicates normal results, as it meets the criteria for a reassuring biophysical profile.
Incorrect Choices:
A: A score of 10 would indicate that the results are equivocal - This is incorrect as a score of 10 would indicate normal results, not equivocal.
C: A score of 6 would indicate that birth should be considered as a possible treatment option - This is incorrect, as a score
A nurse has just received report on 4 neonates in the newborn nursery. Which of the babies should the nurse assess first?
- A. Neonate whose mother is HIV positive.
- B. Neonate whose mother is group B streptococcus positive.
- C. Neonate whose mother’s labor was 12 hours long.
- D. Neonate whose mother gained 45 pounds during her pregnancy.
Correct Answer: B
Rationale: The neonate whose mother is group B streptococcus positive should be assessed first due to the risk of early-onset sepsis.
The nurse is caring for a 45-year-old client who is scheduled to have a chorionic villus sampling. Which information is most important for the nurse to obtain from the client before the procedure?
- A. NPO status
- B. Blood type and Rh
- C. Weeks of gestation
- D. Maternal bleeding disorders
Correct Answer: D
Rationale: The correct answer is D: Maternal bleeding disorders. This information is crucial before a chorionic villus sampling to assess the risk of excessive bleeding during the procedure due to potential clotting issues. Maternal bleeding disorders can increase the risk of complications during the procedure.
A: NPO status is not as critical for this procedure as it does not typically require fasting.
B: Blood type and Rh are important for other purposes but not specifically needed before a chorionic villus sampling.
C: Weeks of gestation is important for determining the timing of the procedure but does not directly impact the safety or success of the procedure.