A nurse is caring for a client during an initial prenatal visit.
The client's last menstrual period was 18 weeks ago.
Which of the following actions should the nurse plan to take?
Obtain the client's personal and family medical history.
Obtain information about prior pregnancies.
Check the client's urine with a reagent strip.
Schedule the client for prenatal laboratory testing.
Discuss chorionic villus sampling with the client.
The Correct Answer is A
Choice A rationale
Obtaining the client's personal and family medical history is essential during the initial prenatal visit. This history helps identify any genetic disorders or chronic conditions that might affect the pregnancy. It also provides insight into the client's overall health and any potential risk factors.
Choice B rationale
Information about prior pregnancies is important but not the first priority. Prior pregnancy information can provide insights into previous complications, but a comprehensive medical history should come first.
Choice C rationale
Checking the client's urine with a reagent strip is not the primary action during an initial visit. Urine tests are useful for detecting infections and certain conditions, but they come after a thorough history has been obtained.
Choice D rationale
Scheduling the client for prenatal laboratory testing is necessary, but it follows the initial assessment and history-taking. Laboratory tests help confirm the pregnancy and assess overall health but are not the first step.
Choice E rationale
Discussing chorionic villus sampling (CVS) is premature at this stage. CVS is a prenatal test conducted around 10-13 weeks for detecting chromosomal abnormalities, but it's not relevant during the initial visit without understanding the client's medical history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A rubella titer of 1: indicates the presence of antibodies against the rubella virus, but this does not confirm the absence of a current infection. The titer represents past exposure or vaccination rather than an active infection.
Choice B rationale
A rubella titer of 1: suggests immunity to the rubella virus, making vaccination unnecessary at this time. Vaccination is typically recommended for those without immunity to prevent future infection.
Choice C rationale
A titer of 1: indicates the presence of antibodies sufficient to confer immunity to the rubella virus. This level is generally considered protective, implying the client has either had the infection before or has been vaccinated.
Choice D rationale
A mild rubella infection would not typically be determined solely by the titer level. Clinical symptoms and further diagnostic tests are required to diagnose an active rubella infection accurately.
Correct Answer is D
Explanation
Choice A rationale
The fetal heartbeat can be heard with a Doppler at the fourth week of gestation is incorrect. At this early stage, the embryonic heart has only just begun to form, and its activity cannot be detected by Doppler.
Choice B rationale
The fetal heartbeat can be heard with a Doppler at the sixth week of gestation is incorrect. Although the heart begins to beat around this time, it is usually too faint to be detected by Doppler.
Choice C rationale
The fetal heartbeat can be heard with a Doppler at the seventh week of gestation is incorrect. It remains challenging to detect the fetal heartbeat this early with standard Doppler equipment.
Choice D rationale
The fetal heartbeat can be heard with a Doppler at the twelfth week of gestation is correct. By the end of the first trimester, the fetal heart is sufficiently developed and strong enough to be detected using Doppler ultrasound, allowing healthcare providers to monitor fetal well-being.
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