A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test.
Which of the following should the nurse include? (Select all that apply)
Fetal neck translucency
Fetal gender
Fetal motion
Fetal breathing
E. Amniotic fluid volume
Correct Answer : C,D,E
The correct answers are Choices C, D, and E.
Choice A rationale
Fetal neck translucency is not typically evaluated during a biophysical profile. It is usually assessed during a first trimester ultrasound to screen for chromosomal abnormalities.
Choice B rationale
Fetal gender is not typically evaluated during a biophysical profile. The focus of a biophysical profile is on assessing the health and well-being of the fetus.
Choice C rationale
Fetal motion is one of the aspects evaluated during a biophysical profile. It is assessed to determine the activity level of the fetus.
Choice D rationale
Fetal breathing is one of the aspects evaluated during a biophysical profile. It is assessed to determine the respiratory function of the fetus.
Choice E rationale
Amniotic fluid volume is one of the aspects evaluated during a biophysical profile. It is assessed to determine the amount of amniotic fluid surrounding the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.
Correct Answer is D
Explanation
Step 1 is to calculate the volume of betamethasone to be drawn up for each dose. The order is to administer betamethasone IM and to repeat the dose after 2 hours. Betamethasone is available as 4mg/mL. Therefore, to administer a dose of 12mg, the nurse would need to draw up 12mg ÷ 4mg/mL = 3mL for each dose.
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