A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?
The client is carrying more than one fetus.
The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor.
An excessive amount of amniotic fluid is present.
There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid.
The Correct Answer is C
Choice A reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible cause of it. Polyhydramnios is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can occur in multiple pregnancies, as the fetuses produce more urine and fluid than a single fetus.
Choice B reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible complication of it. Polyhydramnios can cause fetal anomalies, such as esophageal atresia, anencephaly, or neural tube defects, which impair the swallowing or absorption of the amniotic fluid. Polyhydramnios can also cause fetal growth restriction or distress, as the excess fluid can compress the umbilical cord or the placenta, and reduce the blood flow and oxygen delivery to the fetus.
Choice C reason: This statement is correct, as it is the definition of polyhydramnios, which is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can be diagnosed by ultrasound, and it can cause maternal and fetal complications, such as preterm labor, premature rupture of membranes, placental abruption, or cord prolapse.
Choice D reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a marker of fetal anomalies. Alpha-fetoprotein (AFP) is a protein that is produced by the fetus, and it can be measured in the maternal serum or the amniotic fluid. An elevated level of AFP in the amniotic fluid can indicate fetal anomalies, such as neural tube defects, abdominal wall defects, or renal anomalies, which can cause polyhydramnios.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering before 34 weeks of gestation. Betamethasone stimulates the production of surfactant, which is a substance that prevents the alveoli from collapsing and improves the lung function of the fetus.
Choice B reason: This statement is incorrect, as betamethasone does not affect the cervical dilation, which is a sign of labor progression. Betamethasone does not stop or delay labor, but rather reduces the complications of prematurity, such as respiratory distress syndrome, intraventricular hemorrhage, or necrotizing enterocolitis.
Choice C reason: This statement is incorrect, as betamethasone does not increase the fetal heart rate, which is a measure of fetal well-being. Betamethasone may cause transient fetal bradycardia, which is a decrease in the fetal heart rate, due to the increased vagal tone and blood pressure. The nurse should monitor the fetal heart rate and notify the provider if there are any signs of fetal distress.
Choice D reason: This statement is incorrect, as betamethasone is not used to stop preterm labor contractions, which are caused by the uterine muscle activity. Betamethasone does not have any tocolytic effect, which is the ability to inhibit uterine contractions. Other medications, such as magnesium sulfate, nifedipine, or indomethacin, may be used to stop preterm labor contractions.
Correct Answer is A
Explanation
Choice A reason: To stay with the client and call for help is the highest priority during a seizure, because it ensures the safety of the client and the fetus, and allows the nurse to monitor the vital signs and fetal heart rate. The nurse should also protect the client from injury and turn the client to the side to prevent aspiration.
Choice B reason: To suction the mouth to prevent aspiration is not the highest priority during a seizure, because it can cause more harm than good. Suctioning can stimulate the gag reflex and increase the risk of vomiting and aspiration. It can also injure the oral mucosa and trigger another seizure.
Choice C reason: To administer oxygen by mask is not the highest priority during a seizure, because it may not be effective or necessary. Oxygen administration can be difficult or impossible during a seizure, and it may not improve the oxygen saturation or fetal outcome. Oxygen should only be given if hypoxia is confirmed by pulse oximetry or arterial blood gas analysis.
Choice D reason: To insert an oral airway is not the highest priority during a seizure, because it can be dangerous and contraindicated. Inserting an oral airway can damage the teeth and tongue, and increase the risk of vomiting and aspiration. It can also provoke another seizure or laryngospasm. An oral airway should only be used if the client is unconscious and has no gag reflex.
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