Nokea
The nurse's role in diagnostic testing is to provide which of the following?
- A. Advice to the couple
- B. Information about the tests
- C. Reassurance about fetal safety
- D. Assistance with decision making
Correct Answer: B
Rationale: The correct answer is B: Information about the tests. The nurse's role in diagnostic testing is to educate the couple about the purpose, procedure, risks, and benefits of the tests. This empowers them to make informed decisions. Providing advice (A) may be beyond the nurse's scope. Reassurance about fetal safety (C) is important but not the primary role. While the nurse may assist with decision-making (D), the key focus should be on providing comprehensive information.
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When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: The correct answer is C: 10 weeks. CVS is typically performed between 10-12 weeks of gestation. At this time, there is enough fetal tissue for sampling without significant risk to the pregnancy. Performing CVS earlier (options A, B) may result in insufficient tissue for accurate testing, while performing it later (option D) may increase the risk of procedure-related complications. Option C provides the optimal balance between ensuring accurate results and minimizing potential risks to the pregnancy.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.
The nurse is measuring the fundal height of a patient who is at 34 weeks of gestation. What fundal height measurement is expected for a patient who is at 34 weeks of gestation?
- A. 31 cm
- B. 33 cm
- C. 37 cm
- D. 38 cm
Correct Answer: C
Rationale: The correct answer is C (37 cm) because at 34 weeks of gestation, the fundal height measurement should be approximately equal to the number of weeks of gestation in centimeters. This is known as the "fundal height equals gestational age" rule. Therefore, at 34 weeks, the expected fundal height measurement should be around 34 cm. Option C (37 cm) is the closest to this expected measurement. Options A, B, and D are incorrect as they do not align with the fundal height expected at 34 weeks of gestation. Option A (31 cm) is too low, Option B (33 cm) is also lower than expected, and Option D (38 cm) is too high for 34 weeks of gestation.
A patient is placed on bed rest at home for mild preeclampsia at 38 weeks' gestation. Which of the following must the nurse teach the patient regarding her condition?
- A. Eat a sodium-restricted diet.
- B. Check her temperature 4 times daily.
- C. Report swollen hands and face.
- D. Limit fluids to 1 liter per day.
Correct Answer: C
Rationale: Swelling in the hands and face can be a sign of worsening preeclampsia and should be reported immediately. Sodium restriction and fluid limits are not typically recommended for mild preeclampsia.
A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?
- A. Primary care
- B. Preventive care
- C. Restorative care
- D. Continuing care
Correct Answer: B
Rationale: Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation.