A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis.
The client asks why she is having an ultrasound prior to the procedure.
Which of the following responses by the nurse is appropriate?
"This is a screening tool for spina bifida.”.
"It is useful for estimating fetal age.”.
"It assists in identifying the location of the placenta and fetus.”.
"This will determine if there is more than one fetus.”. .
The Correct Answer is C
Choice A rationale:
"This is a screening tool for spina bifida.”. This statement is incorrect. An ultrasound performed before an amniocentesis is not primarily used as a screening tool for spina bifida. Spina bifida can be detected through other diagnostic tests.
Choice B rationale:
"It is useful for estimating fetal age.”. While ultrasounds can provide information about fetal age, it is not the primary reason for performing an ultrasound before an amniocentesis. The main purpose is to identify the location of the placenta and fetus, which is essential for safely performing the amniocentesis procedure.
Choice C rationale:
"It assists in identifying the location of the placenta and fetus.”. This is the correct answer. An ultrasound before amniocentesis is crucial for locating the fetus and the placenta accurately. This information helps healthcare providers ensure the safe and precise insertion of the needle into the amniotic sac.
Choice D rationale:
"This will determine if there is more than one fetus.”. Determining if there is more than one fetus is an important aspect of prenatal care but is not the primary reason for performing an ultrasound before amniocentesis. It is generally confirmed through earlier ultrasounds during routine prenatal care. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A nurse is reinforcing nutritional teaching with a client who is at 8 weeks of gestation. Which of the following statements should the nurse include? The correct answer is choice B: "You should increase your folic acid intake during your pregnancy.”.
Choice A rationale:
"You should stop taking your prenatal vitamin if you experience nausea.”. This statement is incorrect. Nausea is a common symptom during pregnancy, especially during the first trimester. However, discontinuing prenatal vitamins is not recommended. It's essential to continue taking them to ensure the mother and baby receive adequate nutrients. Prenatal vitamins are designed to provide essential vitamins and minerals that are crucial for the baby's development. Discontinuing them due to nausea could lead to nutrient deficiencies.
Choice C rationale:
"You should limit your iron intake during your first trimester.”. This statement is incorrect. Iron intake should not be limited during the first trimester. Iron is an essential mineral during pregnancy, as the mother's blood volume increases, and iron is required to make more red blood cells to carry oxygen to the baby. Iron deficiency can lead to anemia, which can be harmful to both the mother and the baby. Therefore, iron intake is typically increased during pregnancy to meet the increased demand.
Choice D rationale:
"You should increase your daily calorie intake by 750 calories.”. This statement is not entirely accurate. While it's true that calorie needs increase during pregnancy, the recommended additional calorie intake is generally around 300-500 calories per day, not 750. The exact number can vary from person to person, depending on their pre-pregnancy weight and activity level. Consuming too many extra calories can lead to excessive weight gain, which can have negative consequences for both the mother and the baby. It's important to focus on the quality of calories consumed and ensure they come from nutrient-dense foods.
Correct Answer is A
Explanation
A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; responds to suctioning of the nares with respiration of 20; body pink in color with blue extremities. What should the nurse document as the newborn's 1-min Apgar score? The correct answer is choice B: 7.
Choice A rationale:
Apgar scores are determined by assessing five vital signs in a newborn at 1 and 5 minutes after birth. The vital signs are heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each category is scored from 0 to 2, with 2 being the best score. In this case, the heart rate is 1, the respiratory effort is 1, muscle tone is 1, reflex irritability is 2 (as the newborn responds to suctioning), and color is 2 (as the body is pink). Therefore, the total Apgar score is 7 (1 + 1 + 1 + 2 + 2 = 7).
Choice B rationale:
The heart rate at 1 minute is 110 beats per minute, which is considered normal for a newborn. A slow, weak cry suggests some respiratory effort, which is given a score of 1 on the Apgar scale. Some flexion of extremities also indicates moderate muscle tone and receives a score of 1. Responding to suctioning with respiration indicates good reflex irritability, which is given a score of 2. The body being pink in color is a positive sign for oxygenation and receives a score of 2. Adding up these scores (1 + 1 + 2 + 2) equals 7, which is the 1-minute Apgar score.
Choice C rationale:
Apgar scores are not determined based on gestational age; they focus on the newborn's immediate condition. While gestational age can influence a newborn's health, it is not directly factored into the Apgar score.
Choice D rationale:
The Apgar score is not related to the mother's condition or complications during pregnancy, such as placenta previa. It solely evaluates the newborn's condition at 1 and 5 minutes after birth.
Choice E rationale:
The Apgar score is a quick assessment of the newborn's physical condition and does not consider issues like the mother's gestational diabetes. It focuses on the baby's vital signs and physical appearance to gauge overall well-being.
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