A nurse is caring for a client who is at 38 weeks of gestation and has a score of 10 on her biophysical profile. Which of the following actions should the nurse take?
Administer oxygen and notify the provider.
Assure the client that the score is within the expected range.
Offer the client orange juice and repeat the assessment in 1 hr.
Assist the client into a side-lying position.
The Correct Answer is B
The correct answer is choice B. Assure the client that the score is within the expected range.
Choice A rationale:
Administering oxygen and notifying the provider is not necessary for a biophysical profile (BPP) score of 10. A score of 10 indicates that the fetus is well-oxygenated and there are no signs of distress.
Choice B rationale:
A BPP score of 10 is considered normal and reassuring, indicating that the fetus is well-oxygenated and there are no signs of distress. Therefore, the nurse should assure the client that the score is within the expected range.
Choice C rationale:
Offering the client orange juice and repeating the assessment in 1 hour is not necessary for a BPP score of 10. This action might be considered if the score were lower and there was a need to reassess fetal well-being.
Choice D rationale:
Assisting the client into a side-lying position is not required for a BPP score of 10. This position is typically recommended to improve uteroplacental blood flow in cases of fetal distress or lower BPP scores.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Vaginal hematoma is not the most significant risk in the 4th stage of labor. While vaginal hematomas can occur due to trauma during delivery, they are less common and usually manageable compared to other complications.
Choice B rationale:
Hypoglycemia is not a typical complication in the 4th stage of labor. This stage refers to the immediate postpartum period, during which the mother's blood sugar levels may decrease slightly, but it is not the greatest concern at this stage.
Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid. While it can be a concern during labor, the question specifically refers to the 4th stage, which occurs after the delivery of the placenta. Chorioamnionitis is more relevant to earlier stages of labor.
Choice D rationale:
Uterine hemorrhage is the greatest risk during the 4th stage of labor. This stage, also known as the "placental stage,”. is when the uterus contracts to expel the placenta. If the uterus fails to contract adequately, it can lead to significant bleeding, known as postpartum hemorrhage. This is a critical concern that requires immediate attention to prevent complications.
Choice E rationale:
Dehiscence, which refers to the reopening of a surgical wound, is not a common complication during the 4th stage of labor. The 4th stage primarily focuses on uterine contraction and placental delivery, making dehiscence less relevant in this context.
Correct Answer is C
Explanation
Choice A rationale:
The umbilical cord typically contains two arteries and one vein. Arteries carry oxygen-depleted blood and waste products from the fetus to the placenta for removal, while the vein carries oxygenated blood and nutrients from the placenta to the fetus. This arrangement is essential for maintaining proper fetal circulation during pregnancy.
Choice B rationale:
This choice is incorrect because the umbilical cord usually contains two arteries and one vein, not just one artery and one vein. Having only one artery could indicate a potential vascular abnormality or congenital issue that may require further investigation or medical attention.
Choice C rationale:
This is the correct answer. The umbilical cord usually contains two arteries and one vein. The presence of two arteries allows for the efficient removal of waste products and carbon dioxide from the fetus, while the single vein delivers essential nutrients and oxygen to support the baby's growth and development.
Choice D rationale:
This choice is incorrect as it states two veins and one artery, which is not the typical configuration of blood vessels in the umbilical cord. Having two veins and one artery would disrupt fetal circulation and hinder proper nutrient and waste exchange between the fetus and the placenta.
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