NCLEX Review: NUR 245 Unit 5

NCLEX Review: NUR 245 Unit 5

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview HESI Comprehensive Exam 263 terms choleenggPreview A&P of 52 terms sab A client at 28 weeks gestation is admitted to the labor and birth unit. Which test might be used to assess the client's fetal status?1) Amniocentesis 2) Contraction stress test (CST) 3) Ultrasound for physical structure 4) Biophysical profile (BPP) 4) Biophysical profile would be used to assess the client's fetal status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well- being. Contraction stress test is appropriate in the third trimester. Amniocentesis tests for lung maturity, not overall status.A prenatal client in her second trimester is admitted to the maternity unit with painless, bright red vaginal bleeding. What test might the physician order?1) Contraction stress test (CST) 2) Alpha-fetoprotein (AFP) 3) Amniocentesis 4) Ultrasound 4) An ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding. Alpha- fetoprotein (AFP) is a test used to screen for neural tube defects. A contraction stress test is ordered in the third trimester to evaluate the respiratory function of the placenta. Amniocentesis is a procedure used for genetic diagnosis or, in later pregnancy, for lung maturity studies.The nurse is preparing a prenatal client for a transvaginal ultrasound. What nursing action should be included in the preparations?1) Apply transmission gel over the client's abdomen.2) Advise the client not to empty her bladder.3) Encourage the client to drink 1.5 quarts of fluid.4) Place client in lithotomy position.4) After having the client void, assist her to a lithotomy position for a transvaginal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client's abdomen.

A client in her third trimester has come to the clinic for her first prenatal visit. She asks the nurse whether ultrasound can determine the baby's age. What statement by the nurse would be the best response?1) "The estimate of gestational age may vary by one to three weeks." 2) "The accuracy of ultrasound is the same in the first and third trimesters." 3) "The ultrasound measures gender, not age." 4) "A comprehensive ultrasound is needed for accuracy." 1) The ability to establish fetal age accurately by ultrasound is lost in the third trimester because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound can be used to approximate gestational age within one to three weeks' accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.The physician orders an ultrasound for a prenatal client prior to an amniocentesis. The nurse explains to the client

that the purpose of the ultrasound is to:

1) Locate the placenta.2) Measure the fetus's crown-rump length.3) Determine the gestational sac volume.4) Measure the fetus's biparietal diamet 1) The purpose of the ultrasound before an amniocentesis is to locate the placenta, fetus, and an adequate pocket of fluid. Determination of the gestational sac volume, measuring the crown-rump length, and measuring the biparietal diameter are aspects of assessing fetal well-being (biophysical profile, or BPP), and may or may not be done prior to the amniocentesis, depending on gestational age.The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)?1) A client with multiple gestation.2) A client with an incompetent cervix.3) A client with placenta previa.4) A client with intrauterine growth retardation.4) A contraction stress test (CST) is indicated for a client with intrauterine growth retardation (IUGR), because it will assess the respiratory function of the placenta, which may be adversely affected by the conditions causing IUGR. The contraction stress test is contraindicated for the client with multiple gestation, an incompetent cervix, or placenta previa.A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. What would be an appropriate nursing action to prepare this client for the procedure?1) Encourage the client to take fluids.2) Position the client in a left lateral tilt.3) Administer Rh immune globulin to the client.4) Cleanse the client's abdominal skin with alcohol.2) An appropriate nursing action to prepare this client for amniocentesis would be to position the client in a left lateral tilt to prevent supine hypotension. The skin is cleansed with povidone-iodine (Betadine), not alcohol. Rh immune globulin is appropriate only for nonsensitized Rh-negative women after the procedure.Encouraging the client to take fluids is not appropriate prior to the procedure, because the client may become nauseous.A prenatal client at 30 weeks gestation is scheduled for a nonstress test (NST) and asks the nurse, "What is this test for?" The nurse correctly responds that the test is used to

determine: (Select all that apply.)

1) Fetal well-being 2) Fetal lung maturity 3) Adequate fetal oxygenation 4) Accelerations of fetal heart rate

1, 3, 4

An NST documents fetal well-being by measuring fetal oxygenation and fetal heart rate accelerations, but not fetal lung maturity.

The nurse is teaching a prenatal client about chorionic villus sampling (CVS). The nurse correctly teaches the

client that the risks associated with CVS include: (Select

all that apply.) 1) Maternal hypertension 2) Rupture of membranes 3) Intrauterine infection 4) Spontaneous abortion

2. 3. 4.

A prenatal client at 30 weeks gestation is scheduled for an amniocentesis to determine fetal lung maturity. The

nurse expects the lecithin/sphingomyelin (L/S) ratio to be:

1) 2:1

2) 3:1

3) 0.5:1

4) 1:1

4) After 35 wk, it's 2:1. Prior to 30, it's about 0.5:1. Around 30, it's 1:1.A client who has admitted to heavy alcohol use throughout her pregnancy just delivered a 6-pound baby.Which sign or symptom in the mother should the nurse anticipate in the 12-to-48-hour postpartum period?1) Hypotension 2) Bradycardia 3) Seizures 4) Fever 3) As a result of alcohol dependence, the woman may have withdrawal seizures as early as 12 to 48 hours after she stops drinking. Hypertension and tachycardia are more likely to be experienced postpartum in the alcoholic mother. Fever is not expected.A postpartum client who admits to heavy alcohol use asks the nurse about breast-feeding her baby. The nurse correctly teaches this client that excessive alcohol

consumption while breast-feeding may:

1) Decrease the maternal milk letdown reflex.2) Cause mental retardation in the newborn.3) Cause seizure disorders in the newborn.4) Increase the maternal letdown reflex.1) Excessive alcohol consumption while breast-feeding may decrease, not increase, the maternal milk ejection reflex. Fetuses exposed to heroin in utero may experience seizure disorders as newborns. Mental retardation in the newborn may result from alcohol exposure in utero, not through consumption of breast milk.The nurse is teaching a client with diabetes about insulin requirements during pregnancy. Which statement is true regarding insulin requirements?1) Insulin needs decrease late in the third trimester.2) Insulin needs increase late in the first trimester.3) Insulin needs increase early in the first trimester.4) Insulin needs decrease early in the third trimester.2) Insulin needs increase late in the first trimester and in the third trimester. Insulin needs decrease early in the first trimester.

A prenatal client with diabetes asks the nurse about pregnancy-related complications for her baby from diabetes. For what is the baby at risk when the mother has diabetes? (Select all that apply.) 1) Respiratory distress syndrome 2) Sacral agenesis 3) Hyperactivity 4) Macrosomia

1, 2, 4

The nurse is caring for a laboring client with Type I diabetes. What signs and symptoms would the nurse assess if hypoglycemia was suspected?1) Headache and anorexia 2) Diaphoresis and disorientation 3) Frequent urination and headache 4) Dry skin and blurred vision 2) Hypoglycemia manifests itself during labor in a Type I diabetic with diaphoresis and disorientation. There is usually hunger and decreased urination, with headache and clammy skin with blurred vision.A client with Type I diabetes is admitted to the labor and birthing unit. What nursing action should the nurse perform first?1) Obtain a CBC.2) Assess blood sugar level.3) Check urine for protein.4) Obtain prenatal record.2) The nurse is counseling a prenatal client regarding the need to take folic acid supplements during pregnancy.The nurse also encourages the client to eat foods high in

folic acid, such as:

1) Fruits and fruit juice.2) Fresh green leafy vegetables and legumes.3) Rice and pasta.4) Eggs and yogurt.2) The nurse is caring for a laboring client with sickle cell anemia. Which therapy should the nurse anticipate the physician ordering?1) Diuretics 2) Magnesium sulfate 3) Oxygen 4) Bronchodilators 3) Oxygen supplementation is an anticipated therapy for patients with sickle cell anemia, to reduce the risk of their red blood cells sickling in the presence of decreased oxygen. Diuretics, magnesium sulfate, and bronchodilators are not anticipated for patients with sickle cell anemia.