A nurse is caring for a patient scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation.
Which explanations about this test should the nurse provide to the patient?
This test is a screening for spinal defects in the fetus.
This test assesses various markers of fetal well-being.
This test identifies an Rh incompatibility between the mother and fetus.
This test assesses fetal lung maturity.
The Correct Answer is A
Choice A rationale
The maternal serum alpha-fetoprotein test is a part of what’s often called the “triple screen” that can assess whether a pregnant woman may be at increased risk of carrying a baby with certain disorders, such as neural tube defects (spinal defects) or Down syndrome.
Choice B rationale
While the test can provide information about the risk of certain birth defects, it does not assess various markers of fetal well-being.
Choice C rationale
The test does not identify an Rh incompatibility between the mother and fetus. That would be determined through separate blood tests.
Choice D rationale
The test does not assess fetal lung maturity. Other tests, such as amniocentesis, can provide this information.
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Correct Answer is C
Explanation
Choice A rationale
Abdominal pain during pregnancy can be a normal part of the process as the body changes to accommodate the growing baby. However, severe abdominal pain is not normal and could be a sign of a serious condition such as preterm labor or an ectopic pregnancy.
Choice B rationale
Ballottement refers to a medical sign used in the physical examination of a pregnant woman to detect pregnancy. It involves a quick upward pushing against the uterus and feeling for return impact from the fetus. However, it is not a symptom to report during pregnancy.
Choice C rationale
A sudden gush of fluid from the vagina can be a sign of rupture of membranes, which can lead to premature birth if it occurs before 37 weeks of gestation. This is a critical symptom to report as it may indicate that labor is imminent.
Choice D rationale
Vaginal bleeding can be a sign of several serious conditions in pregnancy such as placenta previa or placental abruption. However, light spotting is common in early pregnancy.
Choice E rationale
Quickening refers to the first movement of the fetus felt by the mother, usually between 18 and 25 weeks of gestation. It is not a symptom to report during pregnancy.
Correct Answer is D
Explanation
Choice A rationale
The symptoms described by the client do not typically align with conditions that would lead to Anticipate A. Anticipate A might be expected for a different set of symptoms or conditions.
Choice B rationale
The symptoms described by the client do not typically align with conditions that would lead to Anticipate B. Anticipate B might be expected for a different set of symptoms or conditions.
Choice C rationale
The symptoms described by the client do not typically align with conditions that would lead to Anticipate C. Anticipate C might be expected for a different set of symptoms or conditions.
Choice D rationale
The client’s symptoms of recent painful sores on the perineum, muscle aches, and chills, along with current discomfort when sitting and mild vaginal itching, could suggest a herpes simplex virus infection or another type of infection. Anticipate D might be an antiviral medication or other treatment to address the suspected condition.
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