A nurse is caring for a client who is at 36 weeks of gestation and experiencing hypertension. Which of the following tests should the nurse use to monitor fetal well-being?
Maternal Hgb and Hct
Coombs test
Biophysical profile
Alpha fetoprotein
The Correct Answer is C
Choice A rationale:
Maternal hemoglobin and hematocrit levels are important indicators of the mother's health but are not direct indicators of fetal well-being.
Choice B rationale:
A Coombs test is performed on newborns to assess for hemolytic disease, not to monitor fetal well-being.
Choice C rationale:
A biophysical profile assesses multiple parameters of fetal well-being, including fetal heart rate, fetal movement, fetal breathing, amniotic fluid volume, and fetal tone.
Choice D rationale:
An alpha-fetoprotein test is a screening test for neural tube defects and chromosomal abnormalities but is not typically used to monitor fetal well-being in hypertensive pregnancies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.
Choice B rationale:
Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.
Choice C rationale:
Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.
Choice D rationale:
Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.
Correct Answer is ["A","B","D","E"]
Explanation
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
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