A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?
Take the mother’s vital signs every 15 minutes.
Send a specimen of the fluid to the laboratory for analysis.
Have a suction catheter available for use at delivery.
Prepare a slide of the fluid for fern testing.
The Correct Answer is C
The correct answer is choice C. Have a suction catheter available for use at delivery. This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia. Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.
Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.
Vital signs should be monitored regularly during labor regardless of the fluid color.
Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.
The laboratory analysis will not change the immediate management of the newborn.
Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.
Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Physiologic jaundice is a common condition in newborns that occurs when the baby’s blood contains an excess of bilirubin, a yellow pigment produced during the normal breakdown of red blood cells.In the womb, the mother’s liver removes bilirubin for the baby, but after birth the baby’s own liver must take over this function.Because the baby has more red blood cells than an adult and their liver is still immature, they may not be able to process all the bilirubin and it may build up in their skin and eyes, causing a yellowish appearance.
Choice A is wrong because it is not an increase in neonatal metabolism that causes physiologic jaundice, but rather a decrease in hepatic metabolism of bilirubin.
Choice C is wrong because it describes a different type of jaundice called hemolytic jaundice, which occurs when there is an incompatibility between the blood types of the mother and the baby, leading to an immune reaction that destroys the baby’s red blood cells faster than they can be replaced.
Choice D is wrong because it confuses the reticuloendothelial system with the hepatic system.
The reticuloendothelial system is a network of cells and tissues that are involved in immune responses and phagocytosis (the ingestion of foreign particles or cells).
The hepatic system is the system of organs and structures that are involved in liver functions, such as bile production and detoxification.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL (17 to 205 micromol/L) for total bilirubin and 0.2 to 1.4 mg/dL (3 to 24 micromol/L) for direct bilirubin.
Physiologic jaundice usually peaks at 3 to 5 days after birth and resolves by 2 weeks of age.
It does not require treatment unless the bilirubin levels are very high or rising rapidly, which may indicate a more serious condition or a risk of brain damage.
Correct Answer is C
Explanation
The correct answer is choice C. Remind the patient that the nurse will stay with her during the examination.
This measure would help reduce the patient’s anxiety by providing emotional support and reassurance.
The patient may feel scared, embarrassed, or vulnerable during the pelvic examination, especially since she is young and pregnant.
Having a trusted person with her can help her cope with these feelings.
Choice A is wrong because it may imply that the examination will be painful and increase the patient’s anxiety.
Choice B is wrong because it may make the patient feel like she is not being treated as an individual and that her concerns are not valid.
Choice D is wrong because it may make the patient feel rushed or pressured and not allow her to ask questions or express her feelings.
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