A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Ultrasound is used to observe for placental maturity in the first trimester."

"Ultrasound is used to detect intrauterine growth restriction in the first trimester."

"Ultrasound is used to determine gestational age in the first trimester."

"Ultrasound is used to perform a biophysical profile in the first trimester."

Answer and Explanation

The Correct Answer is C

Ultrasonography is a diagnostic imaging technique that uses high-frequency sound waves to create images of the internal structures of the body. It is a safe and noninvasive method that can provide valuable information about the pregnancy, such as the number, size, location, and health of the fetus(es), the placenta, the amniotic ﬂuid, and the uterus.
Ultrasonography can be performed at any time during pregnancy, but it is especially useful in the first trimester (the first 12 weeks of pregnancy) for several reasons, such as:

-   To confirm the pregnancy and rule out ectopic pregnancy (a pregnancy that occurs outside the uterus) or molar pregnancy (a pregnancy that develops into an abnormal mass of tissue)
-   To determine gestational age (the length of time since the first day of the last menstrual period) and estimate due date (the expected date of delivery)
-   To screen for chromosomal abnormalities (such as Down syndrome) or structural defects (such as spina bifida) in the fetus
-   To identify multiple gestations (such as twins or triplets) or complications (such as miscarriage or
bleeding)
One of the main uses of ultrasonography in the first trimester is to determine gestational age. This is important because it can aﬀect many aspects of prenatal care and delivery, such as:
-   The timing and accuracy of other tests and procedures
-   The monitoring and evaluation of fetal growth and development
-   The identification and management of potential problems or complications
-   The planning and preparation for labor and delivery
Gestational age can be determined by measuring the crown-rump length (CRL) of the fetus, which is the distance from the top of the head to the bottom of the spine. The CRL can be measured by using a transvaginal ultrasound (an ultrasound probe that is inserted into the vagina) or a transabdominal ultrasound (an ultrasound probe that is moved over the abdomen). The CRL can be compared to a standard growth chart to estimate gestational age. The CRL measurement is most accurate between 7 and 13 weeks of pregnancy .
Therefore, the newly licensed nurse who says that ultrasound is used to determine gestational age in the first trimester indicates an understanding of the teaching.

The other statements show a lack of knowledge or misunderstanding of the uses of ultrasonography in the first trimester:
-   a) "Ultrasound is used to observe for placental maturity in the first trimester." This is not correct because placental maturity is not assessed in the first trimester. Placental maturity refers to the changes that occur in the placenta as it ages and prepares for delivery. Placental maturity can be evaluated by using a grading system that ranges from 0 to 3, based on the appearance of calcifications (deposits of calcium) in the placenta. Placental maturity can be assessed by using a transabdominal ultrasound in the third trimester (after 28 weeks of pregnancy).
-   b) "Ultrasound is used to detect intrauterine growth restriction in the first trimester." This is not correct because intrauterine growth restriction (IUGR) is not detected in the first trimester. IUGR is a condition in which the fetus does not grow as expected and has a low birth weight for its gestational age. IUGR can be caused by various factors, such as placental insufficiency, maternal malnutrition, infection, or chronic disease. IUGR can aﬀect fetal development and increase the risk of complications, such as hypoxia, hypoglycemia, or stillbirth. IUGR can be diagnosed by measuring fetal growth parameters, such as abdominal circumference, head circumference, femur length, and estimated fetal weight. These measurements can be obtained by using a transabdominal ultrasound in the second or third trimester (after 20 weeks of pregnancy).

-   d) "Ultrasound is used to perform a biophysical profile in the first trimester." This is not correct because a biophysical profile (BPP) is not performed in the first trimester. A BPP is a test that evaluates fetal well-being by assessing five parameters: fetal movement, fetal tone, fetal breathing, amniotic ﬂuid volume, and fetal heart rate. A BPP can help detect fetal distress or hypoxia and guide management decisions. A BPP can be performed by using a combination of transabdominal ultrasound and nonstress test (NST) in the third trimester (after 32 weeks of pregnancy).

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Correct Answer is B

Explanation

This is the finding that the nurse should report to the provider following this medication. Butorphanol is an opioid analgesic that can cause respiratory depression as a serious side eﬀect¹. A normal respiratory rate for an adult is 12 to 20 breaths per minute². A respiratory rate of 10/min is below the normal range and could indicate inadequate ventilation and oxygenation. The nurse should monitor the client's oxygen saturation, administer oxygen if needed, and notify the provider of this finding.

The other options are not correct because they are not signs of adverse eﬀects from butorphanol. Let me
explain why:
a) Urinary Output 1 20 mL in 2 hr

This is a normal urinary output for an adult. A normal urinary output is 0.5 to 1 mL/kg/hr³. Assuming an average weight of 70 kg, this would be 35 to 70 mL/hr, or 70 to 140 mL in 2 hr. Therefore, a urinary output of 120 mL in 2 hr is within the normal range and does not need to be reported.
c) Moderate fetal heart rate variability
This is a reassuring sign of fetal well-being. Fetal heart rate variability is the amount of ﬂuctuation in the fetal heart rate from the baseline. Moderate variability is defined as a ﬂuctuation of 6 to 25 beats per minute (bpm) and indicates that the fetus is responsive and has adequate oxygenation⁴. Moderate variability does not need to be reported.
d) Blood pressure 136/88 mm Hg
This is a slightly elevated blood pressure, but not a sign of an adverse eﬀect from butorphanol. Butorphanol does not cause significant changes in blood pressure¹. A normal blood pressure for an adult is less than 120/80 mm Hg⁵. A blood pressure of 136/88 mm Hg is considered elevated, but not hypertensive. The nurse should monitor the client's blood pressure and check for other signs of preeclampsia, such as proteinuria, headache, or visual changes. However, this finding does not need to be reported immediately.

A. "The discharge is common during the first 24 to 72 hours following a circumcision." B. "I will need to obtain a sample of the discharge for laboratory testing." C. "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours." D. "Apply povidone-iodine solution twice daily to the circumcision site."

Correct Answer is A

Explanation

The appropriate response by the nurse is to reassure the client that the discharge is common during the first 24 to 72 hours following a circumcision. This discharge is typically a mixture of blood and serum and is a normal part of the healing process. It is important to provide accurate and reassuring information to alleviate any concerns the client may have.

Option b) "I will need to obtain a sample of the discharge for laboratory testing" is not necessary in this situation. The yellow discharge described by the client is a common and expected occurrence following a circumcision, and routine laboratory testing is not required.

Option c) "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours" is not the recommended approach. It is generally advised to avoid wiping or manipulating the circumcision site during the healing process to prevent irritation or disruption of the healing tissues.

Option d) "Apply povidone-iodine solution twice daily to the circumcision site" is not recommended. Povidone-iodine solution is not typically used for routine care of a circumcision site. It is important to follow the healthcare provider's instructions regarding post-circumcision care, which usually involves keeping the area lean and dry without the use of any specific solutions or ointments.

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A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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