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Which response by the nurse is most accurate?
- A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
- B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
- C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
- D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Correct Answer: C
Rationale: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.
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The 28-year-old pregnant client (G3P2) has just been diagnosed with gestational diabetes at 30 weeks. The client asks what types of complications may occur with this diagnosis. Which complications should the nurse identify as being associated with gestational diabetes? Select all that apply.
- A. Seizures
- B. Large-for-gestational-age infant
- C. Low-birth-weight infant
- D. Congenital anomalies
- E. Preterm labor
Correct Answer: B,D
Rationale: Infants of diabetic mothers can be large as a result of excess glucose to the fetus. Congenital anomalies are more common in diabetic pregnancies. Seizures do not occur as a result of diabetes but can be associated with preeclampsia, another pregnancy complication. Infants of diabetic mothers are usually large for gestational age and do not have a low birth weight. Preterm labor is not typically associated with maternal diabetes.
Which response by the nurse is most appropriate?
- A. A weight gain of about 10 pounds is recommended during pregnancy.
- B. Your weight gain depends on the amount of food that you eat.
- C. It's normal for adolescent girls to be worried about weight gain.
- D. You're average weight gain during pregnancy is between 25 and 35 pounds.
Correct Answer: D
Rationale: The average weight gain of 25-35 pounds is appropriate for a teenager with normal prepregnancy weight, addressing her concerns.
The laboring client presents with ruptured membranes, frequent contractions, and bloody show. She reports a greenish discharge for 2 days. Place the nurse’s actions in the order that they should be completed.
- A. Perform a sterile vaginal exam
- B. Assess the client thoroughly
- C. Obtain fetal heart tones
- D. Notify the health care provider
Correct Answer: C,A,B,D
Rationale: Obtain FHT should be first. The client has ruptured membranes with greenish fluid, and the fetus could be experiencing nonreassuring fetal status. Perform a sterile vaginal exam to determine labor progression. Assess the client thoroughly. This needs to be completed prior to notifying the HCP with the information. Notify the HCP is last of the options. Assessment findings would need to be reported to the HCP. The client should then be moved into an inpatient room.
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
- A. When the first fetal movement is felt
- B. If the breasts become tender
- C. If vaginal bleeding occurs
- D. When experiencing frequent urination
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
- A. Client who is 2 hours post-cesarean birth for a breech baby
- B. Client who delivered a macrosomic baby after a 12-hour labor
- C. Client who has a firm fundus after a vaginal delivery 4 hours ago
- D. Client receiving oxytocin intravenously for past 2 hours
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.