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In preparing a gravid client for a triple screen analysis, which action should the nurse take?

Encourage the client to drink 8 oz of water.

Assist the client to left lateral tilt position.

Prepare to draw blood for analysis.

Apply an external fetal monitor to the abdomen.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Drinking water is not necessary before a triple screen analysis. This test does not require a full bladder.

Choice B rationale

The left lateral tilt position is typically used to prevent supine hypotensive syndrome in pregnant women during ultrasounds, not for a blood draw.

Choice C rationale

A triple screen analysis involves drawing blood from the mother to test for specific markers that indicate the risk of certain fetal abnormalities. Blood sampling is necessary for the analysis.

Choice D rationale

Applying an external fetal monitor is unrelated to a triple screen analysis, which focuses on maternal blood markers rather than fetal heart rate monitoring.

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Correct Answer is B

Explanation

Choice A rationale

Requesting placement of the epidural should be based on the current cervical dilation and labor progress. Administering an epidural too early may lead to prolonged labor and increased risk of interventions.

Choice B rationale

Determining current cervical dilation is essential to assess the progress of labor and to make informed decisions about pain management and the use of epidurals. This ensures appropriate timing for interventions.

Choice C rationale

Decreasing the oxytocin infusion rate would not be the first action without assessing the current cervical dilation and labor progress. Oxytocin adjustments should be based on specific clinical indications and findings.

Choice D rationale

Giving a bolus of intravenous fluids is typically done before administering an epidural to prevent hypotension. However, this should be preceded by assessing cervical dilation to determine the timing and need for an epidural.

A. Obtain consent for the Hepatitis B vaccine. B. Collect a venous specimen for serum glucose level. C. Assess for the presence of the Moro reflex. D. Ensure that zidovudine is given within 6 hours after birth.

Correct Answer is D

Explanation

Choice A rationale

Obtaining consent for the Hepatitis B vaccine is a necessary step in the newborn's care, but it is not the immediate priority for a newborn exposed to HIV. The focus should be on preventing HIV transmission from mother to child.

Choice B rationale

Collecting a venous specimen for serum glucose level is important for assessing the newborn's metabolic status, but it does not directly address the immediate need to reduce the risk of HIV transmission.

Choice C rationale

Assessing for the presence of the Moro reflex is part of a routine newborn examination and is important for evaluating the neurological status of the newborn. However, it does not address the immediate priority of HIV prophylaxis.

Choice D rationale

Ensuring that zidovudine is given within 6 hours after birth is critical for reducing the risk of mother-to-child transmission of HIV. Early administration of antiretroviral medication is essential to prevent viral replication and transmission to the newborn.

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In preparing a gravid client for a triple screen analysis, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control.Findings of the last vaginal exam, performed one hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station.Which action should the nurse implement first?

Correct Answer is B

Explanation

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

Correct Answer is D

Explanation

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