Nokea
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.
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The nurse is caring for a client with a suspected breech presentation. When the nurse performs Leopold's maneuvers, which maneuvers determine the fetal presentation? Select all that apply.
- A. First
- B. Second
- C. Third (Pawlik's maneuver)
- D. Fourth
Correct Answer: C
Rationale: First, the nurse applies gentle pressure just above the symphysis pubis to determine the presenting part (First). Second, the nurse palpates the sides of the uterus to identify the fetal back and small parts (Second). Third, Pawlik’s maneuver involves locating the fetal head in the fundus to confirm the fetal presentation. This maneuver determines the fetal presentation definitively (Correct - C). Fourth, the nurse feels for the fetal buttocks or cephalic prominence to determine the position of the back or head (Fourth). Pawlik's maneuver is crucial in identifying the fetal presentation accurately, making it the correct answer. Other choices are incorrect as they do not directly determine the fetal presentation like Pawlik's maneuver does.
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.
A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.
The nurse is providing patient teaching to a client who plans to bottle feed her newborn infant. Which of the following information should be included in the education session?
- A. The baby should be burped after every 3 ounces of formula.
- B. If the bottle nipple is not filled throughout the feeding, the baby may take in a large amount of air.
- C. The best way to heat formula for the baby is in the microwave.
- D. If the mother is busy with her other children, she can prop the baby bottle up on a blanket or towel.
Correct Answer: B
Rationale: The bottle nipple should be filled with formula throughout the feeding to prevent the baby from taking in air, which can cause discomfort and gas.
A pregnant woman is complaining of ptyalism. The nurse should teach the woman to try which of the following self-care measures?
- A. Use an astringent mouthwash.
- B. Elevate her legs frequently.
- C. Eat high-fiber foods.
- D. Void when the urge is felt.
Correct Answer: A
Rationale: Ptyalism, or excessive salivation, can be managed with astringent mouthwash to reduce saliva production.