Family History: breast cancer, heart disease. Allergy: Penicillin.
Multiple sexual partners.
A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation.
Which of the following actions should the nurse take?
Administer rubella vaccine.
Administer ceftriaxone IM.
Obtain a blood culture.
Obtain a maternal serum alpha-fetoprotein specimen.
The Correct Answer is D
The nurse should obtain a maternal serum alpha-fetoprotein (MSAFP) specimen for a client at 12 weeks of gestation.
MSAFP is a screening tool used to identify fetal neural tube defects (NTDs) such as spina bifida and anencephaly.
Elevated levels of MSAFP indicate an increased risk for NTDs, while low levels indicate an increased risk for chromosomal abnormalities such as Down syndrome.
Administering rubella vaccine (A) is contraindicated during pregnancy as it is a live vaccine and can cause fetal harm.
Administering ceftriaxone IM (B) and obtaining a blood culture (C) are not indicated based on the information provided about the client.
The client's allergy to penicillin is not relevant to the nurse's immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nurse caring for a client who is receiving prenatal care and is at her 24-week appointment should plan to conduct a one-hour glucose tolerance test.
This test is done to screen for gestational diabetes that can develop during pregnancy.
Choice A, Group B strep culture, is not an answer because it is a test usually done between 35-37 weeks of pregnancy to check for the presence of Group B streptococcus bacteria.
Choice B, Rubella titer, is not an answer because it is a blood test usually done early in pregnancy to check for immunity to rubella.
Choice C, Blood type and Rh, is not an answer because it is a blood test usually done early in pregnancy to determine the mother’s blood type and Rh factor.
Correct Answer is A
Explanation
A nurse should discontinue oxytocin if the client experiences uterine hyperkinesia, which is defined as more than 5 contractions in 10 minutes.
Choice B is not correct because contractions lasting 60 seconds are within the normal range.
Choice C is not correct because moderate variability of the fetal heart rate is a reassuring sign.
Choice D is not correct because nonrepetitive early decelerations are generally considered benign and do not require intervention.
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