A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?
Phosphatidylglycerol (PG) absent
Nonstress test is reactive
Lecithin/sphingomyelin (L/S) ratio of 2:1
Biophysical profile score of 8
The Correct Answer is C
Choice A rationale: The presence of phosphatidylglycerol (PG) in the amniotic fluid is another indicator of fetal lung maturity. The absence of PG is associated with an increased risk of respiratory distress syndrome (RDS) in the newborn.
Choice B rationale: A nonstress test is a test performed during pregnancy to evaluate the fetal heart rate in response to fetal movement. It is not directly related to assessing fetal lung maturity.
Choice C rationale: The L/S ratio is an important indicator of fetal lung maturity. Lecithin and sphingomyelin are two surfactants present in the lungs, and the ratio of these two substances increases as the fetal lungs mature. An L/S ratio of 2:1 or greater is considered an indication of lung maturity and suggests that the newborn should be able to breathe adequately after birth.
Choice D rationale: The biophysical profile (BPP) is a prenatal ultrasound assessment of the fetus, which includes evaluating fetal movements, breathing, heart rate, and amniotic fluid volume. While a BPP of 8 is a reassuring score, it does not provide direct information about fetal lung maturity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Auscultating fetal heart tones in the right upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal back is on the right side of the mother's abdomen, and the fetal head is in the fundal portion of the uterus.
Choice B rationale: During Leopold maneuvers, the nurse palpated a round, firm, movable part in the fundal portion of the uterus. This finding corresponds to the fetal head, which is typically located at the top of the uterus (fundus). Additionally, the nurse palpated a long, smooth surface on the mother's right side. This finding indicates the fetal back, which typically lies along the right side of the mother's abdomen, suggesting that the fetus's back is positioned anteriorly (toward the mother's front). The location of the fetal heart is typically best heard over the back of the fetus. Therefore, the nurse should auscultate the fetal heart tones in the maternal quadrant corresponding to the back of the fetus, which is the left lower quadrant.
Choice C rationale: The information from Leopold maneuvers does not indicate the fetal back is in the right lower quadrant. The nurse should not auscultate fetal heart tones in this area.
Choice D rationale: Auscultating fetal heart tones in the left upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal head is in the fundal portion of the uterus and the fetal back is on the right side of the mother's abdomen. The fetal heart is usually best heard over the back of the fetus, which is not in the left upper quadrant.
Correct Answer is C
Explanation
Choice A rationale: A gynaecoid-shaped pelvis is considered the most favorable for childbirth and is not a contributing cause of difficult, prolonged labor.
Choice B rationale: The fetal lie refers to the orientation of the baby's spine in relation to the mother's spine. A longitudinal lie (baby's spine parallel to the mother's spine) is the typical and preferred position for birth and is not a cause of difficult, prolonged labor.
Choice C rationale: A persistent occiput posterior (OP) position, where the baby's head faces the mother's abdomen instead of her back, is a known contributing factor to difficult and prolonged labor. The baby's position in the birth canal can affect the progress and ease of labor.
Choice D rationale: Fetal attitude refers to the position of the baby's body parts in relation to each other. General flexion, where the baby's head is flexed forward and the limbs are flexed, is the normal attitude for birth and does not contribute to difficult, prolonged labor.
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