A nurse is caring for a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following indicates that the fetal lungs are mature?

Biophysical profile score of 8

Phosphatidylglycerol (PG) absent

Lecithin/sphingomyelin (L/S) ratio of 2:1

Nonstress test is reactive

Answer and Explanation

The Correct Answer is C

Choice A reason: A biophysical profile score of 8 is a good indicator of fetal well-being, but it does not measure the fetal lung maturity. It consists of five parameters: fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, and nonstress test.

Choice B reason: Phosphatidylglycerol (PG) is a phospholipid that is present in the fetal lung surfactant. Its presence indicates that the fetal lungs are mature, while its absence does not rule out the possibility of maturity.

Choice C reason: Lecithin and sphingomyelin are two phospholipids that are found in the fetal lung surfactant. The L/S ratio is the ratio of lecithin to sphingomyelin in the amniotic fluid. A ratio of 2:1 or higher indicates that the fetal lungs are mature and can produce enough surfactant to prevent respiratory distress syndrome.

Choice D reason: A nonstress test is a test that measures the fetal heart rate and its response to fetal movements. A reactive test means that the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice in a 20-minute period. This indicates that the fetus is healthy and well-oxygenated, but it does not reflect the fetal lung maturity.

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Correct Answer is A

Explanation

Choice A reason: Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy because it can indicate the well-being of the fetus and the presence of any complications, such as cord compression, prolapse, or infection.

Choice B reason: Observing the color and consistency of fluid is an important nursing action following an amniotomy, but it is not the priority. It can provide information about the gestational age, the presence of meconium, or the risk of infection.

Choice C reason: Assessing the client's temperature is an important nursing action following an amniotomy, but it is not the priority. It can help detect signs of infection, such as chorioamnionitis, which can affect both the mother and the fetus.

Choice D reason: Evaluating the client for the presence of chills and increased tenderness using palpation is an important nursing action following an amniotomy, but it is not the priority. It can also help detect signs of infection, such as chorioamnionitis, which can cause fever, abdominal pain, and uterine contractions.

A. My baby's heart rate will be monitored during the test. B. I will take 20 to 30 minutes to complete the test. C. I should schedule the test when the baby is usually active. D. I will have to lie on my back during the test.

Correct Answer is D

Explanation

Choice A reason: This is a correct statement, as the NST measures the fetal heart rate and its response to fetal movement. The nurse will place two belts around the client's abdomen, one to monitor the heart rate and one to monitor the contractions.

Choice B reason: This is a correct statement, as the NST usually takes 20 to 30 minutes to complete. The nurse will look for at least two accelerations of the fetal heart rate within a 20-minute period.

Choice C reason: This is a correct statement, as the NST is more likely to be reactive (normal) when the baby is active. The client may be asked to eat or drink something before the test to stimulate the baby's movement.

Choice D reason: This is an incorrect statement, as the client does not have to lie on her back during the test. Lying on the back can compress the inferior vena cava and reduce the blood flow to the placenta. The client can lie on her side or sit in a reclining chair during the test.

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A nurse is caring for a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following indicates that the fetal lungs are mature?

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