A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse’s most appropriate response
The test results are within normal limits.”
Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
Multiple-marker screening
The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history?
Maternal diabetes
What point in the pregnancy is the most accurate time to determine gestational age through ultrasound?
First trimester
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?
A neural tube defect
When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
10 weeks
Which aspect of fetal diagnostic testing is most important to expectant parents?
Safety of the fetus
The nurse’s role in diagnostic testing is to provide which of the following
Information about the tests
Which factors should be considered a contraindication for transcervical chorionic villus sampling?
Positive for group B Streptococcus
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
Determine fetal lung maturity.
What does optimal nursing care after an amniocentesis include?
Monitoring uterine activity
What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?
Reactive
What is the purpose of initiating contractions in a contraction stress test (CST)?
Apply a stressful stimulus to the fetus.
A biophysical profile is performed on a pregnant patient. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs),limited gross movements, opening and closing of hang indicating the presence of fetal tone,and adequate amniotic fluid index (AFI) meeting criteria. Which answer would be the correct interpretation of this test result?
A score of 8 would indicate normal results
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
Contact the health care provider to discuss birth options for the patient.
A pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient’s plan of care?
Refer to the physician for additional testing.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered
RhoGAM if the patient is Rh-negative
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
A 24-year-old gravida 1, para 0, who has diabetes
Which complication could occur as a result of percutaneous umbilical blood sampling(PUBS)?
Fetal bradycardia
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient’s health care provider. When is the best time for the nurse to schedule the patient’s ultrasound?
Immediately
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. The nurse determines that the patient understands the teaching when she states that will be collected for the initial screening process?
Blood
A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
NST reactive, reassuring
Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)? (Select all that apply.)
Twin gestation
Incorrect gestational age assessment of a normal fetus—estimation is earlier in the pregnancy
Threatened abortion
Transvaginal ultrasonography is often performed during the first trimester. A 6-week-gestation patient expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be necessary to determine which of the following? (Select all that apply)
Multifetal gestation
Bicornuate uterus
Presence and location of pregnancy
Presence of ovarian cysts
A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator (VAS) test. Which should the nurse include in the response? (Select all that apply.)
The test uses sound to elicit fetal movements.
The test may confirm nonreactive nonstress test results.
Vibroacoustic stimulation can be repeated at 1-minute intervals up to three times.
The nurse is instructing a patient on how to perform kick counts. Which information should the nurse include in the teaching session? (Select all that apply.
Use a clock or timer when performing kick counts.
Protocols can provide a structured timetable for concentrating on fetal movements.
You should lie on your side, place your hands on the largest of the abdomen,and concentrate on the number of movements felt.
The nurse is preparing a patient for a nonstress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.)
Have the patient sit in a recliner with the head elevated 45 degrees.
Apply electronic monitoring equipment to the patient’s abdomen.
Instruct the patient to press an event marker every time she feels fetal movement.
The breastfeeding patient should be taught a safe method to remove her breast from the baby’s mouth. Which suggestion by the nurse is most appropriate?
Break the suction by inserting your finger into the corner of the infant’s mouth.
Which woman is most likely to continue breastfeeding beyond 6 months
A woman who avoids using bottles
In which condition is breastfeeding contraindicated?
Human immunodeficiency virus infection
Which type of formula should not be diluted before being administered to an infant?
Ready to use
How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day?
100 to 110
Which hormone is essential for milk production?
Prolactin
Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex?
Place the infant to the breast.
Which is the first step in assisting the breastfeeding mother to nurse her infant?
Assess the woman’s knowledge of breastfeeding.
Which of the following is an important consideration in positioning a newborn for breastfeeding?
Placing the infant at nipple level facing the breast
The patient should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following?
Unwrap and gently arouse the infant.
To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?
Breast-feed frequently and for adequate lengths of time
As the nurse assists a new mother with breastfeeding, the mother asks, “If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” The nurse’s best response is that it contains
important immunoglobulins
How should the nurse explain mild supply and demand when responding to the question, “Will I produce enough milk for my baby as she grows and needs more milk at each feeding?”
The mother’s milk supply will increase as the infant demands more at each feeding.
Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma?
Position the infant so the nipple is far back in the mouth.
A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse’s first response be
Try massaging the area and apply heat; it is probably a plugged duct.”
Which is an important consideration regarding the storage of breast milk?
Can be kept refrigerated for 72 hours
What is the most serious consequence of propping an infant’s bottle?
Aspiration
A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse’s best response?
“Bacteria can grow rapidly in warm milk.”
A new mother asks whether she should feed her newborn colostrum because it is not “real milk.” The nurse’s best answer includes which information?
Colostrum is high in antibodies, protein, vitamins, and minerals.
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
have the patient put the infant to her breast more frequently.
A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, what score would the nurse assign to this feeding session?
6 and further teach and assist the mother in feeding activities.
A mother conveys concern over the fact that she is not certain if her newborn is receiving enough nutrients from breastfeeding. This is the baby’s first clinic visit after birth. What information can you provide that will help alleviate her fears regarding nutrient status for her newborn?
Monitor the infant’s output; as long as at least six or more diapers are changed in a 24-hour period, the baby is receiving sufficient intake.
A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurse’s most appropriate response?
Breast milk is low in vitamin D and supplementation with 400 IU is
A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding?
“I should encourage my baby to consume the entire amount of formula prepared for each feeding.
The nurse is teaching a postpartum patient different holds for breastfeeding. Which of the following figures depicts the football hold frequently used for patients who have had a cesarean birth?
B
Late in pregnancy, the patient’s breasts should be evaluated by the nurse to identify any potential concerns related to breastfeeding. Which of the following nipple conditions make it necessary to intervene prior to birth. (Select all that apply.)
Flat nipples
Inverted nipples
Nipples that contract when compressed
For which infant should the nurse anticipate the use of soy formula? (Select all that apply.)
Infant with galactosemia
Infant with lactase deficiency
Infant with a malabsorption disorder
A new mother asks the nurse, “How will I know early signs of hunger in my baby?” The nurse’s best response is which of the following? (Select all that apply.)
Rooting
Lip smacking
Sucking on the hands