A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?
The client is carrying more than one fetus.
The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor.
An excessive amount of amniotic fluid is present.
There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid.
The Correct Answer is C
Choice A reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible cause of it. Polyhydramnios is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can occur in multiple pregnancies, as the fetuses produce more urine and fluid than a single fetus.
Choice B reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible complication of it. Polyhydramnios can cause fetal anomalies, such as esophageal atresia, anencephaly, or neural tube defects, which impair the swallowing or absorption of the amniotic fluid. Polyhydramnios can also cause fetal growth restriction or distress, as the excess fluid can compress the umbilical cord or the placenta, and reduce the blood flow and oxygen delivery to the fetus.
Choice C reason: This statement is correct, as it is the definition of polyhydramnios, which is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can be diagnosed by ultrasound, and it can cause maternal and fetal complications, such as preterm labor, premature rupture of membranes, placental abruption, or cord prolapse.
Choice D reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a marker of fetal anomalies. Alpha-fetoprotein (AFP) is a protein that is produced by the fetus, and it can be measured in the maternal serum or the amniotic fluid. An elevated level of AFP in the amniotic fluid can indicate fetal anomalies, such as neural tube defects, abdominal wall defects, or renal anomalies, which can cause polyhydramnios.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Uterine enlargement greater than expected for gestational age is not a typical manifestation of ectopic pregnancy, because the embryo is implanted outside the uterus, usually in the fallopian tube. The uterus may be slightly enlarged due to hormonal changes, but not more than expected for the gestational age.
Choice B reason: Unilateral, cramp-like abdominal pain is a common manifestation of ectopic pregnancy, because the embryo grows and stretches the fallopian tube, causing inflammation and irritation. The pain may be mild or severe, depending on the size and location of the ectopic pregnancy, and may radiate to the shoulder or back.
Choice C reason: Severe nausea and vomiting is not a specific manifestation of ectopic pregnancy, because it can be caused by other conditions, such as hyperemesis gravidarum, gastroenteritis, or appendicitis. The client may have mild nausea and vomiting due to hormonal changes, but not more than usual for the gestational age.
Choice D reason: Large amount of vaginal bleeding is not a usual manifestation of ectopic pregnancy, because the bleeding is usually internal, into the abdominal cavity. The client may have spotting or light bleeding due to the detachment of the endometrium, but not heavy or profuse bleeding.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as surfactant is not an antibiotic and does not treat infections. Surfactant is a substance that is naturally produced by the lungs to reduce the surface tension and prevent the alveoli from collapsing. Premature infants may have insufficient surfactant, which can cause RDS.
Choice B reason: This statement is partially true, as surfactant can help reduce episodes of periodic apnea, which is a condition where the newborn stops breathing for more than 20 seconds. However, this is not the main purpose of surfactant therapy, and other interventions, such as oxygen, ventilation, and caffeine, may be needed to treat apnea.
Choice C reason: This statement is correct, as surfactant improves the ability of the baby's lungs to exchange oxygen and carbon dioxide, which are essential for life. Surfactant therapy can improve the lung function, reduce the need for mechanical ventilation, and prevent complications, such as bronchopulmonary dysplasia and pulmonary hemorrhage.
Choice D reason: This statement is false, as surfactant does not affect the level of sedation in the newborn. Surfactant is administered through an endotracheal tube, which may require sedation to reduce discomfort and agitation. The nurse should monitor the newborn's vital signs, oxygen saturation, and pain level during and after the procedure.
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