A nurse in a health clinic is caring for a client who arrived for their initial visit after a positive home pregnancy test. The nurse should identify that which of the following actions should occur during the initial visit?

Screening for group B streptococcus B-hemolytic (GBS).

Performing a complete physical assessment.

Measuring fundal height.

Performing a urinalysis.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Screening for group B streptococcus B-hemolytic (GBS) is typically performed between 35-37 weeks gestation, not during the initial visit. This screen aims to reduce neonatal GBS infections.

Choice B rationale

A complete physical assessment is necessary during the initial prenatal visit to establish a baseline health status and identify any potential health issues or risk factors in pregnancy.

Choice C rationale

Measuring fundal height is usually done after 20 weeks gestation to assess fetal growth and development, not during the initial prenatal visit, where the focus is on baseline assessments.

Choice D rationale

Performing a urinalysis is part of the initial prenatal visit to screen for urinary tract infections, glucose, protein, and other substances, ensuring maternal and fetal health.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale

Amniocentesis assesses fetal lung maturity, genetic disorders, and infections, not preeclampsia. Preeclampsia diagnosis involves blood pressure, proteinuria, and other lab tests. Normal blood pressure: <120/80 mm Hg. Proteinuria: >300 mg/day.

Choice B rationale

A non-stress test measures fetal heart rate response to movements, evaluating fetal well-being. Normal fetal heart rate: 110-160 bpm. Accelerations: 15 bpm increase for at least 15 seconds.

Choice C rationale

Chorionic villus sampling assesses chromosomal abnormalities, genetic disorders, not neural tube defects. Neural tube defect screening: maternal serum alpha-fetoprotein levels, ultrasound. Normal alpha-fetoprotein: 0.5-2.5 MoM.

Choice D rationale

A full bladder helps lift the uterus for better visualization during ultrasound, especially in early pregnancy. This improves image quality for assessing fetal development and other structures.

Choice E rationale

Oral glucose tolerance test assesses gestational diabetes by measuring blood glucose levels, not fetal activity. Normal fasting blood glucose: <95 mg/dL. 1-hour post-glucose: <180 mg/dL.

A. Avoid fried and spicy foods. B. Lie down soon after eating. C. Eat dry crackers before getting out of bed in the morning. D. Avoid overfilling your stomach.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Avoiding fried and spicy foods can reduce nausea by preventing gastric irritation and reflux, common in pregnancy due to hormonal changes. Ginger, bland foods are better alternatives.

Choice B rationale

Lying down after eating may exacerbate nausea and acid reflux due to the relaxation of the lower esophageal sphincter caused by pregnancy hormones. Remain upright for at least 30 minutes.

Choice C rationale

Eating dry crackers before getting out of bed helps stabilize blood glucose levels, reducing morning sickness. This is effective due to hormonal fluctuations affecting digestion in pregnancy.

Choice D rationale

Avoiding overfilling the stomach prevents excessive distension, reducing pressure on the stomach and lower esophageal sphincter, thus minimizing nausea and reflux. Smaller, frequent meals are recommended.

Choice E rationale

This choice is invalid, as it does not directly correlate with recommended nausea management strategies in pregnancy. Focus on dietary adjustments and hydration instead.

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A nurse in a health clinic is caring for a client who arrived for their initial visit after a positive home pregnancy test. The nurse should identify that which of the following actions should occur during the initial visit?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D"]

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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