A client at 40 weeks of gestation is about to undergo a biophysical profile. The nurse should explain that this profile focuses on which of the following parameters? (Select all that apply.)
Fetal breathingA. Fetal motionB. Nuchal translucencyC. Amniotic fluid volumeD. Fetal genderE. 1. Rationale:)HWDOEUHDWKLQJLVFRUUHFW$ELRSK\VLFDOSURILOHLQFOXGHVHYDOXDWLRQRIIHWDOEUHDWKLQJmovements. )HWDOPRWLRQLVFRUUHFW$ELRSK\VLFDOSURILOHLQFOXGHVHYDOXDWLRQRIJURVVERG\movement of the fetus.1XFKDOWUDQVSDUHQF\LVLQFRUUHFW7KLVVFUHHQLQJWHFKQLTXHPHDVXUHVIOXLGLQWKHnape of the fetal neck via ultrasound, but it is not a parameter of the biophysical profile.$PQLRWLFIOXLGYROXPHLVFRUUHFW$ELRSK\VLFDOSURILOHLQFOXGHVDTXDOLWDWLYHevaluation of amniotic fluid volume.)HWDOJHQGHULVLQFRUUHFW$OWKRXJKXOWUDVRQRJUDSK\FDQGHWHUPLQHJHQGHUWKHbiophysical profile measures fetal well-being, not gender.
CAA_DetailedAnswerKey created 05/15/2016page 1 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105 A client delivered a 34-week, 1,550-g newborn who has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral thermal environment becauseRationale:Preterm newborns have a large body surface area for their weight.he has a small body surface for his weight.A. Rationale:The goal is not simply to expose the infant to heat, but to an environment that avoids not just hypothermia, but hyperthermia as well. In a neutral thermal environment, oxygen consumption is minimal. Both hypothermia and hyperthermia can adversely affect oxygenation.heat increases flow of oxygen to his extremities.B. Rationale:Preterm newborns have poor body control of temperature and needs immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity. They require an external heat source that regulates their immediate environment via a sensor attached to the skin.
his temperature control mechanism is immature.C. Rationale:Dry heat can impede the drainage of mucus.heat facilitates the drainage of mucus.D. 2. CAA_DetailedAnswerKey created 05/15/2016page 2 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105 A nurse is caring a client who is 1 day postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?Rationale:Because the swelling is present in both breasts and there is no redness or pain, this client is not likely to have mastitis. This client is more likely to have engorgement. The nurse should assist the client to breastfeed frequently and use a well-fitting bra. It also might help to use warmth, such as a warm shower. If the breasts are severely engorged, it might help to express some milk to soften the breasts prior to nursing.Swelling in both breastsA. Rationale:Cracked and bleeding nipples are not signs of mastitis. However, cracked nipples are a risk for developing mastitis. Cracked and sore nipples may occur until the woman¶s nipples adapt to the friction from nursing. Cracked and sore nipples also may indicate tissue damage from inadequate latching. The nurse should reinforce appropriate breastfeeding techniques.Cracked and bleeding nipplesB. Rationale:Mastitis often appears as a red, hard, and painful area. Although mastitis may occur in both breasts, it is usually unilateral. After delivery, the nurse should monitor a woman¶s breasts for signs of mastitis and reinforce instruction for breast self-examination.
Red and painful area in one breastC. Rationale:A client may have an elevated temperature during the initial 24 hr postpartum. This is due to fluid loss during labor and delivery, sleep deprivation, and physiologic response to the birthing process. A temperature that persists after 24 hr postpartum may indicate an infection.Temperature of 38R& 100R) D. 3. CAA_DetailedAnswerKey created 05/15/2016page 3 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105 A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for postpartal hemorrhage due to uterine atony because she had aRationale:A midline episiotomy does not cause uterine atony.midline episiotomy.A. Rationale:The risk of uterine atony increases whenever the uterus has been overstressed or overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr).
precipitous delivery.B. Rationale:The risk of hemorrhage does not increase after an uncomplicated vaginal delivery.vaginal delivery.C. Rationale:This injury does not increase the risk of uterine atony.periurethral tear.D. 4. CAA_DetailedAnswerKey created 05/15/2016page 4 of 159Detailed Answer KeyMaternity review test 1
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Fetal breathingA. Fetal motionB. Nuchal translucencyC. Amniotic fluid volumeD. Fetal genderE. 1. Rationale:)HWDOEUHDWKLQJLVFRUUHFW$ELRSK\VLFDOSURILOHLQFOXGHVHYDOXDWLRQRIIHWDOEUHDWKLQJmovements. )HWDOPRWLRQLVFRUUHFW$ELRSK\VLFDOSURILOHLQFOXGHVHYDOXDWLRQRIJURVVERG\movement of the fetus.1XFKDOWUDQVSDUHQF\LVLQFRUUHFW7KLVVFUHHQLQJWHFKQLTXHPHDVXUHVIOXLGLQWKHnape of the fetal neck via ultrasound, but it is not a parameter of the biophysical profile.$PQLRWLFIOXLGYROXPHLVFRUUHFW$ELRSK\VLFDOSURILOHLQFOXGHVDTXDOLWDWLYHevaluation of amniotic fluid volume.)HWDOJHQGHULVLQFRUUHFW$OWKRXJKXOWUDVRQRJUDSK\FDQGHWHUPLQHJHQGHUWKHbiophysical profile measures fetal well-being, not gender.
CAA_DetailedAnswerKey created 05/15/2016page 1 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105 A client delivered a 34-week, 1,550-g newborn who has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral thermal environment becauseRationale:Preterm newborns have a large body surface area for their weight.he has a small body surface for his weight.A. Rationale:The goal is not simply to expose the infant to heat, but to an environment that avoids not just hypothermia, but hyperthermia as well. In a neutral thermal environment, oxygen consumption is minimal. Both hypothermia and hyperthermia can adversely affect oxygenation.heat increases flow of oxygen to his extremities.B. Rationale:Preterm newborns have poor body control of temperature and needs immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity. They require an external heat source that regulates their immediate environment via a sensor attached to the skin.
his temperature control mechanism is immature.C. Rationale:Dry heat can impede the drainage of mucus.heat facilitates the drainage of mucus.D. 2. CAA_DetailedAnswerKey created 05/15/2016page 2 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105 A nurse is caring a client who is 1 day postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?Rationale:Because the swelling is present in both breasts and there is no redness or pain, this client is not likely to have mastitis. This client is more likely to have engorgement. The nurse should assist the client to breastfeed frequently and use a well-fitting bra. It also might help to use warmth, such as a warm shower. If the breasts are severely engorged, it might help to express some milk to soften the breasts prior to nursing.Swelling in both breastsA. Rationale:Cracked and bleeding nipples are not signs of mastitis. However, cracked nipples are a risk for developing mastitis. Cracked and sore nipples may occur until the woman¶s nipples adapt to the friction from nursing. Cracked and sore nipples also may indicate tissue damage from inadequate latching. The nurse should reinforce appropriate breastfeeding techniques.Cracked and bleeding nipplesB. Rationale:Mastitis often appears as a red, hard, and painful area. Although mastitis may occur in both breasts, it is usually unilateral. After delivery, the nurse should monitor a woman¶s breasts for signs of mastitis and reinforce instruction for breast self-examination.
Red and painful area in one breastC. Rationale:A client may have an elevated temperature during the initial 24 hr postpartum. This is due to fluid loss during labor and delivery, sleep deprivation, and physiologic response to the birthing process. A temperature that persists after 24 hr postpartum may indicate an infection.Temperature of 38R& 100R) D. 3. CAA_DetailedAnswerKey created 05/15/2016page 3 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105 A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for postpartal hemorrhage due to uterine atony because she had aRationale:A midline episiotomy does not cause uterine atony.midline episiotomy.A. Rationale:The risk of uterine atony increases whenever the uterus has been overstressed or overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr).
precipitous delivery.B. Rationale:The risk of hemorrhage does not increase after an uncomplicated vaginal delivery.vaginal delivery.C. Rationale:This injury does not increase the risk of uterine atony.periurethral tear.D. 4. CAA_DetailedAnswerKey created 05/15/2016page 4 of 159Detailed Answer KeyMaternity review test 1
Downloaded by Daynelys Fuentes ()lOMoARcPSD|12481105
