A nurse is reinforcing teaching about a biophysical profile (BPP) with a client who is at 38 weeks of gestation. Which of the following statements should the nurse include in the teaching?
This test measures amniotic fluid volume.
You will receive Rh(D) immune globulin prior to this test.
This test is used to assess uterine activity.
Your bladder needs to be full to perform this test.
The Correct Answer is A
Choice A reason: The nurse should include the statement that "This test measures amniotic fluid volume” in the teaching about the biophysical profile (BPP). The rationale for this is that the BPP is a prenatal screening tool that assesses the well-being of the fetus. One of the components of the BPP is the measurement of amniotic fluid volume, which helps to evaluate fetal kidney function and overall fetal health.
Choice B reason:
The nurse should not include the statement about receiving Rh(D) immune globulin prior to the test because it is not directly related to the biophysical profile (BPP). Rh(D) immune globulin is given to Rh-negative pregnant women to prevent hemolytic disease of the newborn (HDN) if the fetus is Rh-positive. While this may be important information during pregnancy, it is not specific to the BPP.
Choice C reason:
The nurse should not include the statement that "This test is used to assess uterine activity” in the teaching about the BPP. The BPP is a test focused on evaluating fetal well-being and not uterine activity. Uterine activity is typically assessed through other methods, such as monitoring contractions during labor.
Choice D reason:
The correct answer is not Choice D. The nurse should not include the statement that "Your bladder needs to be full to perform this test” in the teaching about the BPP. This statement is incorrect because a full bladder is not necessary for the BPP. Instead, the BPP involves the use of ultrasound to assess fetal movements, breathing, muscle tone, and amniotic fluid volume, and a full bladder is not a requirement for this assessment.
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Related Questions
Correct Answer is C
Explanation
Birth weight has doubled.
Choice A reason:
The nurse should not expect a positive Babinski sign in a 4-year-old child during a well-child visit. The Babinski sign is a reflex seen in infants up to about 1 year of age and disappears as the nervous system matures. Its presence in a 4-year-old would be abnormal and may indicate neurological issues.
Choice B reason:
The nurse should not expect birth height to double in a 4-year-old child during a well-child visit. While children do experience significant growth in their early years, it is unlikely that birth height will have doubled by the age of 4. Doubling of birth height would be an atypical finding.
Choice C reason:
The correct choice. The nurse should expect that the child's birth weight has doubled during a well-child visit. From birth to age 4, children typically experience substantial weight gain, and doubling of birth weight is a common milestone in healthy development.
Choice D reason:
The nurse should not expect the presence of permanent teeth in a 4-year-old child during a well-child visit. Permanent teeth typically begin to emerge around 6 years of age and continue to erupt over the following years. The appearance of permanent teeth at age 4 would be premature and unusual.
Correct Answer is A
Explanation
Choice A reason:
Hypothermia. Hypothermia refers to a condition where the body temperature drops significantly below the normal range. However, in cases of acute opioid toxicity, the opposite effect is usually observed. Opioids can cause respiratory depression, leading to a decrease in the body's ability to regulate temperature, resulting in hyperthermia, not hypothermia.
Choice B reason:
Hypertension. Acute opioid toxicity typically causes respiratory depression, which can lead to a decrease in blood pressure rather than hypertension. Opioids are central nervous system depressants that slow down the body's vital functions, including heart rate and blood pressure.
Choice C reason:
Diaphoresis. Diaphoresis is the medical term for excessive sweating. While it may occur in some cases of opioid toxicity due to the body's response to stress or increased sympathetic activity, it is not a specific and consistent finding. It is not as characteristic as other symptoms associated with opioid toxicity.
Choice D reason:
Mydriasis. Mydriasis refers to the dilation of the pupils. This is a hallmark sign of opioid toxicity. Opioids can affect the autonomic nervous system, leading to pupillary constriction (miosis) in most cases. However, when opioid toxicity is severe or acute, the pupils may dilate, resulting in mydriasis.
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