Nokea
Which of the following tests is used to assess fetal lung maturity?
- A. Non-stress test
- B. Biophysical profile
- C. Amniocentesis
- D. Lecithin-sphingomyelin (L/S) ratio
Correct Answer: D
Rationale: The correct answer is D: Lecithin-sphingomyelin (L/S) ratio. This test is used to assess fetal lung maturity by measuring the ratio of two substances found in the amniotic fluid. An L/S ratio greater than 2:1 is indicative of mature fetal lungs. This test is crucial in determining if a baby can breathe adequately after birth. The other choices are incorrect because: A) Non-stress test monitors fetal heart rate and movements, B) Biophysical profile assesses fetal well-being, and C) Amniocentesis is a procedure to collect amniotic fluid for genetic testing.
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A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include?
- A. Lay the baby on his stomach to nap during the daytime.
- B. Change smoke detector batteries every other year.
- C. Use a car seat when traveling by airplane
- D. Place a plastic waterproof sheet over the crib bedding
Correct Answer: C
Rationale: Using a car seat during air travel ensures the newborn's safety during takeoff, landing, and turbulence.
The nurse continues to care for the client who is at 30 weeks of
gestation.
Exhiont 2
Vital Signs
1000:
Temperature 37.4"C（99.3*F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 95% on room air
1100:
Temperature 37° C (98.6° F)
Heart rate 92/min
Respiratory rate 24/min
Blood pressure 156/96 mm Hg
Oxygen saturation 94% on room air
1400:
Temperature 37.2°C（98.9*F）
Heart rate 80/min
Respiratory rate 14/min
Blood pressure 170/112 mm Hg
oxygen saturation 92% on room air
Complete the following sentence by using the list of options. Based on the client findings, the nurse should first admister-----------------and then prepare to administer-----------------------
- A. calcium gluconate
- B. hydralazine
- C. nifedipine
Correct Answer: B,A
Rationale: Rationale:
First administer hydralazine ✅
The client is experiencing severe hypertension (BP 170/112 mm Hg at 1400), which indicates preeclampsia with severe features.
Hydralazine is a fast-acting antihypertensive that helps lower blood pressure and reduce the risk of stroke, placental abruption, or fetal compromise.
Then prepare to administer calcium gluconate ✅
If the client is receiving magnesium sulfate for seizure prevention (common in severe preeclampsia), calcium gluconate is the antidote in case of magnesium toxicity (which can cause respiratory depression or cardiac arrest).
The nurse should have calcium gluconate readily available in case of toxicity signs like loss of deep tendon reflexes, respiratory depression, or cardiac arrhythmias.
Notify the provider 🚨
The severely elevated BP (170/112 mm Hg) and potential risk for eclampsia (seizures) require immediate provider notification for further management.
What is the recommended method of screening for Down syndrome during pregnancy?
- A. Maternal serum screening
- B. Fetal ultrasound
- C. Chorionic villus sampling (CVS)
- D. Amniocentesis
Correct Answer: A
Rationale: The recommended method for screening for Down syndrome during pregnancy is maternal serum screening. This test measures specific hormones and proteins in the mother's blood to assess the risk of chromosomal abnormalities in the fetus. It is a non-invasive and low-risk option that can be done early in pregnancy. Fetal ultrasound (B) is used to evaluate fetal growth and anatomy but is not specific for Down syndrome screening. Chorionic villus sampling (C) and amniocentesis (D) are diagnostic tests that involve sampling fetal tissue and carry a higher risk of complications compared to maternal serum screening.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Continuing to take insulin as prescribed, even when experiencing nausea and vomiting, is essential for maintaining blood glucose control during pregnancy.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: A urine output of 280 mL within 8 hours is low and may indicate dehydration, which is a concern in a client with hyperemesis gravidarum.