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
Answer: D
Rationale:
(A) "Your partner will apply continuous, firm pressure between your thumb and index finger": This statement is not appropriate for describing counterpressure during labor. Counterpressure typically involves applying pressure to areas such as the lower back or sacrum, not between the thumb and index finger.
(B) "Your partner will apply pressure to the top of your uterus during contractions": This statement is not appropriate. Applying pressure to the top of the uterus during contractions could be harmful and is not recommended as a counterpressure technique during labor. Counterpressure is generally applied to the lower back or hips to alleviate pain.
(C) "Your partner will apply steady pressure with a tennis ball to your finger": This statement is not correct. Counterpressure during labor involves applying pressure to the lower back or hips, not to the fingers. A tennis ball may be used, but it is applied to the lower back or sacral area, not the fingers.
(D) "Your partner will apply upward pressure on you": This statement is appropriate. During labor, counterpressure is often applied by the partner to the lower back or hips, pressing upward or in a direction that helps alleviate the pain caused by contractions, particularly in cases of back labor. This technique can help relieve discomfort by counteracting the pressure from the baby's head against the mother's spine.
Correct Answer is C
Explanation
A nurse caring for a client who has hyperemesis gravidarum should anticipate urine ketones test.
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that results in dehydration, weight loss, and ketosis.
Urine ketones test is done to check for ketosis which is a sign of starvation 2.
Choice A, Rapid plasma reagin, is not an answer because it is a blood test used to screen for syphilis.
Choice B, Prothrombin time, is not an answer because it is a blood test used to measure how long it takes for blood to clot.
Choice D, Urine culture, is not an answer because it is a test used to detect and identify bacteria or yeast that may be causing a urinary tract infection.
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