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A client at 12 weeks' gestation asks about the purpose of nuchal translucency testing. What is the nurse's best response?
- A. It screens for fetal anemia.
- B. It detects neural tube defects.
- C. It screens for chromosomal abnormalities.
- D. It confirms gestational age.
Correct Answer: C
Rationale: The correct answer is C because nuchal translucency testing is primarily used to screen for chromosomal abnormalities, such as Down syndrome, in the fetus. This test measures the thickness of the fluid-filled space at the back of the baby's neck. It is typically done between 11 and 14 weeks of pregnancy. This testing helps to assess the risk of genetic conditions in the fetus. Option A is incorrect because nuchal translucency testing does not screen for fetal anemia. Option B is incorrect because it does not detect neural tube defects. Option D is incorrect because it does not confirm gestational age.
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A client at 10 weeks' gestation reports frequent nausea. What dietary recommendation should the nurse provide?
- A. Avoid eating salty snacks.
- B. Drink fluids between meals.
- C. Consume three large meals a day.
- D. Avoid eating protein-rich foods.
Correct Answer: B
Rationale: The correct answer is B: Drink fluids between meals. This recommendation helps manage nausea during pregnancy by preventing dehydration, which can worsen symptoms. Consuming fluids between meals also helps maintain hydration and prevents an empty stomach, which can trigger nausea. A: Avoiding salty snacks is not directly related to managing nausea. C: Consuming three large meals a day may worsen nausea due to overeating. D: Avoiding protein-rich foods is not recommended as they are important for fetal development and overall nutrition during pregnancy.
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
Which assessment finding suggests that the laboring client's
- B. Reflex grade 0
- C. Urine output 60
- D. Generalized seizure
Correct Answer: D
Rationale: The correct answer is D, Generalized seizure. During labor, a generalized seizure is a critical finding that indicates eclampsia, a severe complication of pregnancy characterized by seizures, hypertension, and proteinuria. This requires immediate medical intervention to prevent harm to the mother and baby. Reflex grade 0 (choice B) is not a typical assessment finding during labor, and it does not indicate any immediate life-threatening condition. Urine output of 60 (choice C) is within the normal range and does not suggest any immediate critical issue. Therefore, choice D is the correct answer due to the urgency and severity of the condition it represents.
A client at 34 weeks' gestation reports decreased fetal movements. What should the nurse advise first?
- A. Drink a glass of juice and lie down.
- B. Come to the clinic immediately.
- C. Monitor fetal movements for 24 hours.
- D. Call the healthcare provider tomorrow.
Correct Answer: A
Rationale: The correct answer is A: Drink a glass of juice and lie down. This advice is based on the concept that consuming juice can stimulate fetal movements due to the increase in blood sugar levels. Lying down also helps the client focus on feeling the movements. This initial step is non-invasive and can potentially address the decreased fetal movements promptly. Choices B and D delay action, which can be dangerous if there is a significant issue with the baby. Choice C might lead to unnecessary waiting and potential risks if the fetus is in distress.
A client is admitted with a vaginal bleeding at 10 weeks' gestation and her fundal height 13cm. Which potential problem should you investigate?
- A. Hydatidiform mole
- B. DIC
- C. Previa
- D. Abruptio placenta
Correct Answer: C
Rationale: The correct answer is C: Previa. At 10 weeks' gestation, fundal height should be close to the pelvic brim, not 13cm above it. This suggests placenta previa, where the placenta implants low in the uterus, causing bleeding. Hydatidiform mole would typically present with earlier bleeding and a larger uterus. DIC and abruptio placenta are not supported by the information given at this gestational age.