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 A
Explanation
Choice A rationale: The rooting reflex is a natural reflex in newborns that helps them find the nipple for feeding. When the baby's cheek is touched or stroked, they will turn their head in that direction and open their mouth, searching for the breast or bottle.
Choice B rationale: The Babinski reflex is a different reflex, which involves the fanning and curling of the toes when the sole of the foot is stroked. It is not related to sucking or feeding.
Choice C rationale: The Moro reflex, also known as the startle reflex, occurs when a newborn is startled by a sudden noise or movement. The baby reacts by extending their arms and legs and then bringing them back toward the center of their body. It is not related to sucking or feeding.
Choice D rationale: The stepping reflex is observed when a newborn is held upright with their feet touching a solid surface. The baby will make stepping movements, but it is not related to sucking or feeding.
Correct Answer is D
Explanation
Choice A rationale: Applying identification bands is an essential step in newborn care, but it is not the priority immediately after delivery. The nurse should first address the baby's physiological needs, such as drying and maintaining body temperature.
Choice B rationale: Assessing and documenting the Apgar score is important for evaluating the newborn's overall condition and response to delivery, but it is not the priority immediately after delivery.
Choice C rationale: Administering phytonadione (vitamin K) to prevent bleeding disorders in the newborn is essential, but it can be done after drying and stabilizing the baby's body temperature.
Choice D rationale: After ensuring a patent airway, the nurse's priority should be to dry the newborn. Drying the newborn is important for maintaining body temperature and preventing heat loss, especially during the immediate post-delivery period. Wet newborns can lose heat rapidly through evaporation, so drying the baby helps prevent hypothermia and stabilize the baby's body temperature.
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