A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?
This test determines the estimated date of birth.
The client will need to be NPO for 8 hr prior to the test.
The nurse will initiate an IV prior to this test.
The test predicts fetal well-being in the third trimester.
The Correct Answer is D
Choice D rationale:
The correct answer is Choice D. The biophysical profile is a prenatal test used to assess fetal well-being in the third trimester of pregnancy. It is not used to determine the estimated date of birth (Choice A), as that is typically calculated based on the first day of the last menstrual period and confirmed or adjusted by early ultrasounds.
The test also does not require the client to be NPO (nothing by mouth) for 8 hours prior to the test (Choice B). This restriction is commonly associated with certain medical procedures, but it is not applicable to the biophysical profile.
Furthermore, there is no need to initiate an IV (intravenous line) before the biophysical profile (Choice C). The test is non-invasive and involves the use of ultrasound and fetal heart rate monitoring. The biophysical profile assesses several fetal parameters, such as fetal movement, fetal tone, fetal breathing movements, amniotic fluid volume, and the fetal heart rate. These parameters help evaluate the well-being and health of the baby. The test is often recommended in cases of high-risk pregnancies, decreased fetal movement, or other conditions that may warrant closer monitoring of the baby's condition. By knowing that the biophysical profile predicts fetal well-being in the third trimester, the nurse can provide accurate information to the client, reassuring them about the health of their baby and explaining the importance of the test in ensuring a safe delivery and healthy outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: “You must be feeling very scared.” This response is an example of therapeutic communication, where the nurse acknowledges the client’s feelings and provides emotional support without making assumptions or giving false reassurances.
Choice A rationale: While it’s true that the presence of a neonatal unit equipped to handle emergencies is reassuring, this response does not address the client’s immediate emotional needs or fears. It’s important for the nurse to recognize and validate the client’s feelings rather than focusing solely on the facilities available.
Choice B rationale: This choice demonstrates empathy and understanding. It allows the client to express their feelings and concerns, which is a crucial aspect of providing emotional support during labor. By acknowledging the client’s potential fear, the nurse opens the door for further communication and support.
Choice C rationale: This response minimizes the client’s individual feelings by suggesting that everyone has the same worries. It can make the client feel that their concerns are not unique or taken seriously, which is not conducive to establishing trust or providing individualized care.
Choice D rationale: This choice provides false reassurance. At 32 weeks of gestation, while the prognosis for the baby is generally good, there are still risks associated with preterm birth. It’s important not to make definitive statements about outcomes that cannot be guaranteed.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
The nurse should report the blood pressure findings to the provider because there is a significant increase in both systolic and diastolic blood pressure. At 0900, the blood pressure was 156/90 mm Hg, and at 1000, it increased to 160/96 mm Hg. This significant elevation in blood pressure can be a cause for concern as it may indicate the development of gestational hypertension or preeclampsia, which can be dangerous for both the client and the fetus.
Choice B rationale:
Cerebral manifestations are not mentioned in the nurse's notes or vital signs and are not relevant to the given scenario. Therefore, this choice is not applicable in this case.
Choice C rationale:
The nurse should report the fetal heart rate findings to the provider because it is not included in the vital signs section of the nurse's notes. Monitoring the fetal heart rate is essential to ensure the well-being of the fetus, and any abnormalities or changes in the fetal heart rate should be promptly reported to the healthcare provider for further evaluation.
Choice D rationale:
The nurse should report the respiratory rate findings to the provider. Although the respiratory rate seems to be within the normal range (22/min at 0900 and 21/min at 1000), it is a vital sign that should be closely monitored in pregnant clients. Any sudden changes or abnormalities in the respiratory rate may indicate respiratory distress or other health issues that need medical attention. Choices E and F rationale: Deep tendon reflexes and gastrointestinal assessment findings are not mentioned in the nurse's notes or vital signs. These options are not applicable in this scenario and do not require reporting to the provider.
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