Family History: breast cancer, heart disease. Allergy: Penicillin.
Multiple sexual partners.
A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation.
Which of the following actions should the nurse take?
Administer rubella vaccine.
Administer ceftriaxone IM.
Obtain a blood culture.
Obtain a maternal serum alpha-fetoprotein specimen.
The Correct Answer is D
The nurse should obtain a maternal serum alpha-fetoprotein (MSAFP) specimen for a client at 12 weeks of gestation.
MSAFP is a screening tool used to identify fetal neural tube defects (NTDs) such as spina bifida and anencephaly.
Elevated levels of MSAFP indicate an increased risk for NTDs, while low levels indicate an increased risk for chromosomal abnormalities such as Down syndrome.
Administering rubella vaccine (A) is contraindicated during pregnancy as it is a live vaccine and can cause fetal harm.
Administering ceftriaxone IM (B) and obtaining a blood culture (C) are not indicated based on the information provided about the client.
The client's allergy to penicillin is not relevant to the nurse's immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct answer: C-"You should hold your newborn in your arms when you introduce him to your toddler.”
Choice A is not an answer because this approach is not suitable for dealing with regressive behaviors in toddlers. Regressive behavior, such as wanting to sleep in the crib or revert to bottle-feeding, is a normal response to the stress of a new sibling. Instead of punishment, parents should provide reassurance, comfort, and understanding. Time-outs may exacerbate feelings of insecurity rather than alleviate them.
Choice B is not an answer because While transitioning a toddler out of the crib can be a part of preparation, it should not be rushed. Doing so too early may create unnecessary stress for the toddler. The best time to make significant changes (like transitioning to a bed) is when the toddler is ready, and it should be done with care and gradual preparation, not too close to the arrival of the baby.
Choice C is the most appropriateanswer becauseIt’s important to allow the toddler to feel involved and included in the process, but holding the newborn during the introduction helps minimize feelings of jealousy and ensures the toddler doesn't feel displaced. Holding the baby allows the toddler to approach the situation more calmly, and it can also help foster a sense of love and comfort for both the toddler and the newborn.
Choice D:While it’s important to reassure the toddler that they are still loved and important, this statement might unintentionally increase anxiety or make the toddler feel less valued. Instead, the nurse should encourage a positive approach, where the toddler can learn how to be a helper and feel involved in the care of the newborn. It’s essential to focus on inclusivity rather than highlighting potential feelings of neglect.
Correct Answer is C
Explanation
A nurse assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation should indicate the need for further diagnostic testing if there are no late decelerations noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
Choice A is incorrect because an increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal result.
Choice B is incorrect because irregular contractions of 10 to 20 seconds in duration that are not felt by the client do not indicate the need for further diagnostic testing.
Choice D is incorrect because three fetal movements perceived by the client in a 20-min testing period do not indicate the need for further diagnostic testing.
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