A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?
Phosphatidylglycerol (PG) absent
Nonstress test is reactive
Lecithin/sphingomyelin (L/S) ratio of 2:1
Biophysical profile score of 8
The Correct Answer is C
Choice A rationale: The presence of phosphatidylglycerol (PG) in the amniotic fluid is another indicator of fetal lung maturity. The absence of PG is associated with an increased risk of respiratory distress syndrome (RDS) in the newborn.
Choice B rationale: A nonstress test is a test performed during pregnancy to evaluate the fetal heart rate in response to fetal movement. It is not directly related to assessing fetal lung maturity.
Choice C rationale: The L/S ratio is an important indicator of fetal lung maturity. Lecithin and sphingomyelin are two surfactants present in the lungs, and the ratio of these two substances increases as the fetal lungs mature. An L/S ratio of 2:1 or greater is considered an indication of lung maturity and suggests that the newborn should be able to breathe adequately after birth.
Choice D rationale: The biophysical profile (BPP) is a prenatal ultrasound assessment of the fetus, which includes evaluating fetal movements, breathing, heart rate, and amniotic fluid volume. While a BPP of 8 is a reassuring score, it does not provide direct information about fetal lung maturity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: This statement is correct. Burping the baby halfway through each feeding can help release air and prevent discomfort from gas build-up.
Choice B rationale: This statement is correct. It is essential to watch for signs of satiety in the baby, such as slowing down sucking, turning away from the bottle, or becoming relaxed.
Stopping the feeding when the baby is full helps prevent overfeeding.
Choice C rationale: This statement indicates a need for further teaching. The duration of feeding can vary for different babies, and it is not advisable to limit the feeding time to a specific duration like 10 to 15 minutes. Babies have different feeding patterns and may take longer or shorter periods to finish a feeding. It is essential to allow the baby to feed until they are full and satisfied.
Choice D rationale: This statement is correct. It is safe and appropriate to give formula to the baby at room temperature, or it can be warmed if the baby prefers it that way. However, never heat the formula in the microwave as it can create hot spots that may burn the baby's mouth. Instead, warm the formula by placing the bottle in a bowl of warm water. Always test the temperature on the inside of your wrist before feeding the baby to ensure it's not too hot.
Correct Answer is D
Explanation
Choice A rationale: While adequate rest and sleep are essential postpartum, the client's symptoms of feeling down and sad may be indicative of postpartum depression and should be further evaluated.
Choice B rationale: Counseling may be helpful, but the priority is to first assess and screen for postpartum depression before making additional recommendations.
Choice C rationale: While antidepressant medications might be necessary for postpartum depression, the initial step should be to assess and screen for depression using the appropriate tool.
Choice D rationale: The client's statement and symptoms raise concerns about possible postpartum depression. Using a postpartum depression screening tool will help the nurse assess the severity of the client's symptoms and determine the appropriate course of action.
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