Nokea
Which of the following findings in an 8-week gestation client, G2 P1001, should the nurse highlight for the nurse midwife? Select all that apply.
- A. Body mass index of 17 kg/m².
- B. Rubella titer of 1:8.
- C. Blood pressure of 100/60 mm Hg.
- D. Hematocrit of 30%.
Correct Answer: A
Rationale: A low BMI, low rubella titer, and low hematocrit are all concerning findings that should be highlighted for further evaluation. A blood pressure of 100/60 mm Hg is within normal limits.
You may also like to solve these questions
What is the purpose of the Leopold's maneuver in labor and delivery?
- A. to assess fetal presentation and position
- B. to assess fetal position and the location of the placenta
- C. to assess uterine tone and fetal heart rate
- D. to assess the fetal heart rate pattern
Correct Answer: A
Rationale: The purpose of Leopold's maneuver in labor and delivery is to assess fetal presentation and position. Step 1 evaluates the fundal grip to determine the fetal part. Step 2 assesses the sides of the abdomen to identify the fetal back. Step 3 determines the presenting part and position. Step 4 confirms the presenting part and its mobility. This systematic approach helps determine the position of the fetus in the uterus. Choices B, C, and D are incorrect as they do not align with the specific purpose of Leopold's maneuver, which is primarily focused on assessing fetal presentation and position.
The nurse is caring for a pregnant patient who is 22 weeks gestation and is concerned about her weight gain. Which of the following statements by the patient indicates the need for further teaching?
- A. I should aim to gain 1 to 2 pounds per week during my pregnancy.
- B. I will avoid eating extra food to prevent excessive weight gain.
- C. I can eat for two during my pregnancy to ensure the baby's growth.
- D. I will maintain a healthy diet and exercise regularly to support my pregnancy.
Correct Answer: C
Rationale: Correct Answer: C - "I can eat for two during my pregnancy to ensure the baby's growth."
Rationale:
1. Eating for two is a common misconception; the pregnant woman only needs an additional 300-500 calories per day.
2. Overeating can lead to excessive weight gain which may pose risks to both the mother and the baby.
3. The statement does not reflect an accurate understanding of healthy nutrition during pregnancy.
Summary of Incorrect Choices:
A: Choosing to gain 1 to 2 pounds per week aligns with healthy weight gain during pregnancy.
B: Avoiding excessive food intake is an appropriate strategy to prevent excessive weight gain.
D: Maintaining a healthy diet and regular exercise are essential for supporting a healthy pregnancy.
A nurse is caring for a laboring person and is monitoring for signs of fetal distress. Which finding is the most concerning in this situation?
- A. Late decelerations
- B. Bradycardia
- C. Tachycardia
- D. Variable decelerations
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can lead to fetal hypoxia and distress. This is the most concerning finding as it indicates a problem with oxygen delivery to the fetus. Bradycardia (B) and Tachycardia (C) can also be concerning, but late decelerations are more specific to fetal distress. Variable decelerations (D) are caused by cord compression and are concerning but not as indicative of fetal distress as late decelerations.
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?
- A. Hemophilia
- B. Sickle cell anemia
- C. A neural tube defect
- D. Abnormal lecithin-to-sphingomyelin ratio
Correct Answer: C
Rationale: An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter maternal serum, indicating a neural tube defect.
A pregnant patient at 26 weeks gestation reports frequent headaches and blurred vision. What should the nurse do first?
- A. Encourage the patient to take over-the-counter pain medication for relief.
- B. Monitor the patient's blood pressure and check for signs of preeclampsia.
- C. Advise the patient to rest and stay hydrated to alleviate symptoms.
- D. Schedule a follow-up appointment for further evaluation in a few days.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure and check for signs of preeclampsia. At 26 weeks gestation, headaches and blurred vision could be symptoms of preeclampsia, a serious condition in pregnancy. Monitoring blood pressure is crucial as high blood pressure is a key indicator. Preeclampsia can lead to severe complications for both the mother and baby if left untreated. Encouraging over-the-counter pain medication (Choice A) may mask symptoms without addressing the underlying cause. Rest and hydration (Choice C) are important, but immediate evaluation for preeclampsia is necessary. Scheduling a follow-up appointment (Choice D) delays potential diagnosis and treatment.