An 18-week pregnant client was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks about the next steps.
What should the nurse advise?
Reassure the client that the AFP results could be a false reading.
Discuss options for intrauterine surgical correction of congenital defects.
Inform her that a repeat AFP test should be conducted.
Explain that a sonogram should be scheduled for definitive results.
The Correct Answer is D
Choice A rationale
While it’s true that AFP results can sometimes be false readings, it’s not the most appropriate advice for the nurse to give in this situation. Simply reassuring the client without suggesting further investigation could potentially overlook a serious condition.
Choice B rationale
Discussing options for intrauterine surgical correction of congenital defects at this stage is premature. The elevated AFP level alone does not confirm the presence of congenital defects, and suggesting surgical intervention may cause unnecessary anxiety.
Choice C rationale
Informing the client that a repeat AFP test should be conducted is a reasonable suggestion. However, it’s not the most appropriate next step in this case. A repeat test would provide more information, but it wouldn’t give definitive results about the cause of the elevated AFP level.
Choice D rationale
Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Reviewing the pattern of the fetal heart rate is important but not the immediate first step when a client in active labor needs to use the restroom. The nurse should first assess the progress of labor.
Choice B rationale: Checking the client's bladder is necessary, especially if the bladder is full, as it can affect labor progress. However, the priority is to assess the cervix first to ensure the client is not in an advanced stage of labor before addressing bladder concerns.
Choice C rationale: Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.
Choice D rationale: Testing the pH of the vaginal fluid can be part of assessing for the presence of amniotic fluid, but it is not the first step when a client in active labor expresses the need to use the restroom. Cervical assessment takes priority in this situation.
Correct Answer is A
Explanation
Choice A rationale
In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.
Choice B rationale
While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.
Choice C rationale
Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.
Choice D rationale
Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.
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