The nurse is preparing a client for a biophysical profile (BPP). What does this test assess?

Correct Answer: B

Rationale: The correct answer is B) Amniotic fluid index and fetal well-being. The biophysical profile (BPP) is a prenatal test that assesses the well-being of the fetus by evaluating specific parameters including fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume (amniotic fluid index), and fetal heart rate reactivity. This test provides valuable information about the fetal health and helps in determining the need for further intervention or monitoring. Option A) Fetal genetic disorders is incorrect because the BPP does not assess genetic disorders; it focuses on the immediate well-being of the fetus. Option C) Maternal blood flow is incorrect as the BPP specifically evaluates fetal parameters and not maternal factors. Option D) Cervical length is incorrect as this parameter is not part of the BPP assessment; cervical length is more relevant in assessing the risk of preterm labor. Educationally, understanding the purpose and components of the BPP is crucial for nurses caring for pregnant women. This test aids in identifying potential fetal distress or compromise, guiding timely interventions to optimize outcomes for both the mother and the baby. Nurses need to interpret BPP results accurately to provide appropriate care and support to pregnant clients.

Correct Answer: A

Rationale: In the context of caring for a client with gestational hypertension, it is crucial for the nurse to be vigilant for signs of worsening condition that could indicate a progression to a more serious complication like preeclampsia. The symptom that should be reported immediately in this scenario is A) Headache unrelieved by acetaminophen. Severe headaches can be a warning sign of worsening hypertension or preeclampsia, which can lead to serious complications for both the mother and baby. Failure to address this symptom promptly could result in significant harm. Option B) Slight swelling of the hands is a common symptom in pregnancy and may not necessarily indicate a serious problem unless it is severe and accompanied by other concerning symptoms. Option C) Mild nausea after eating is also a common occurrence during pregnancy and is not typically a cause for immediate concern unless it is persistent, severe, or accompanied by other symptoms. Option D) Fatigue at the end of the day is a common symptom in pregnancy and is not typically indicative of a serious complication like preeclampsia. Educationally, it is important for nurses to understand the significance of monitoring for signs and symptoms of gestational hypertension and preeclampsia, as these conditions can have serious implications for both the mother and baby if not identified and managed promptly. Nurses should be equipped to differentiate between normal pregnancy symptoms and those that require immediate attention to provide safe and effective care to pregnant clients.

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn care, the most effective intervention for a client in the first stage of labor experiencing severe lower back pain is to encourage frequent position changes (Option B). This intervention is based on the principles of optimizing fetal oxygenation and blood flow by relieving pressure on the mother's blood vessels and enhancing comfort during labor. Encouraging position changes helps to alleviate the intensity of back pain by redistributing the pressure on the lower back and promoting better fetal positioning for labor progression. It also assists in enhancing maternal blood circulation and reducing the risk of fetal distress. This non-pharmacological approach aligns with the goal of promoting physiologic birth and minimizing unnecessary medical interventions during labor. Administering an epidural block (Option A) may be effective for pain relief but is not the first-line option for addressing lower back pain in the initial stage of labor. Epidural blocks carry risks such as hypotension and prolonged labor, and should be reserved for cases where non-pharmacological interventions are ineffective. Applying a heating pad (Option C) may provide temporary relief for muscle tension but does not address the underlying causes of lower back pain in labor. Moreover, the use of heat modalities during labor should be monitored closely to prevent overheating and potential harm to the fetus. Performing a sterile vaginal exam (Option D) is not indicated for managing lower back pain in labor. Vaginal exams are typically conducted to assess cervical dilation and fetal descent, not for pain management purposes. In conclusion, understanding the rationale behind each intervention in the context of maternal newborn care is crucial for providing safe and effective care to laboring clients. Encouraging frequent position changes is the optimal choice to address severe lower back pain in the first stage of labor, promoting comfort, optimal fetal positioning, and minimizing the need for pharmacological interventions.

Correct Answer: B

Rationale: In the context of caring for a client with suspected placenta previa, the priority nursing intervention is to monitor fetal heart rate and maternal vital signs (Option B). This is crucial because placenta previa can lead to significant maternal hemorrhage and compromise fetal well-being due to poor placental perfusion. Monitoring fetal heart rate and maternal vital signs allows the nurse to assess for any signs of distress in both the mother and the baby. Any sudden changes in vital signs or fetal heart rate may indicate a worsening condition and prompt the need for immediate intervention or delivery. Performing a sterile vaginal examination (Option A) is contraindicated in placenta previa as it can lead to further disruption of the placenta and increase the risk of hemorrhage. Administering oxytocin to stop bleeding (Option C) is not appropriate without a clear understanding of the cause of bleeding, as oxytocin can exacerbate bleeding in placenta previa. Encouraging the client to ambulate (Option D) is not a priority when there is a risk of significant bleeding and compromised fetal well-being. In an educational context, understanding the priority interventions in obstetric emergencies like placenta previa is essential for nurses to provide safe and effective care to pregnant clients. Prioritizing assessments and interventions based on the client's condition can significantly impact outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In the context of maternal health during pregnancy, anemia is a common concern due to the increased demands on the mother's body for adequate blood supply to support both her and the developing fetus. The correct answer, option A, states a hemoglobin level of 10 g/dL, which supports the diagnosis of anemia. Hemoglobin is a protein found in red blood cells responsible for carrying oxygen throughout the body. During pregnancy, a hemoglobin level below 11 g/dL is considered indicative of anemia due to the expansion of plasma volume, which can dilute the concentration of red blood cells. Therefore, a hemoglobin level of 10 g/dL at 20 weeks' gestation raises suspicion for anemia. Analyzing the incorrect options: B) Platelet count of 150,000 mm3: Platelets are involved in blood clotting, not in diagnosing anemia. C) Hematocrit of 40%: While hematocrit measures the proportion of red blood cells in the blood, a specific hemoglobin level is more indicative of anemia. D) White blood cell count of 8,000 mm3: White blood cells are part of the immune system and are not directly related to diagnosing anemia. Educationally, understanding the importance of interpreting lab values in the context of pregnancy helps nurses provide optimal care to both the mother and the fetus. Recognizing the significance of hemoglobin levels in assessing for anemia during pregnancy is crucial for timely intervention and management to promote positive maternal and neonatal outcomes.