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 C
Explanation
Choice A rationale: Placing elbow restraints is not a recommended practice for preterm newborns. Restraints are used in some cases to prevent the baby from pulling on tubes or lines, but it is not primarily for energy conservation.
Choice B rationale: While frequent position changes are important to prevent pressure ulcers and promote comfort, they may not necessarily help conserve energy in a preterm newborn.
Choice C rationale: Preterm newborns have limited energy reserves, and conserving energy is essential for their growth and development. Clustering care activities involves combining nursing care tasks to allow for longer periods of uninterrupted rest for the baby. This approach reduces the baby's energy expenditure and promotes better weight gain and stability.
Choice D rationale: While gentle touch and massage can be beneficial for preterm newborns to promote bonding and relaxation, it may not directly conserve energy as cluster care does.
Correct Answer is B
Explanation
Choice A rationale: Placing the infant in a prone position (lying face down) after feeding is not recommended for a baby with gastroesophageal reflux. The prone position can increase the risk of choking and is not helpful in managing reflux.
Choice B rationale: For an infant with gastroesophageal reflux, placing the baby in an upright position after feeding can help prevent or reduce reflux episodes. Keeping the infant in an upright position allows gravity to assist in keeping stomach contents down and reduces the likelihood of reflux into the esophagus.
Choice C rationale: Placing the infant on the right side after feeding is also not recommended for managing gastroesophageal reflux. The right-side position may not be as effective in preventing reflux as the upright position.
Choice D rationale: Placing the infant on the left side after feeding is not the preferred position for managing gastroesophageal reflux. The left-side position may not be as effective in preventing reflux as the upright position.
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