A nurse is reinforcing teaching with a client about laboratory testing during pregnancy.Which of the following statements should the nurse include in the teaching?
A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
A glucose tolerance test will be performed to predict hyperglycemia in your baby.
A multiple marker screening will be performed to identify neural tube defects.
A group B streptococcus screening will be performed to determine the presence of STIs.
The Correct Answer is C
Choice A rationale
A Papanicolaou test, commonly known as a Pap smear, is used to detect cervical cancer and precancerous changes in the cervix. It does not detect herpes simplex type 1. Herpes simplex virus (HSV) testing is typically done through a swab of the lesion or blood tests to detect antibodies.
Choice B rationale
A glucose tolerance test is performed during pregnancy to screen for gestational diabetes, not to predict hyperglycemia in the baby. This test helps identify how well the mother’s body is managing glucose and ensures that both mother and baby remain healthy during pregnancy.
Choice C rationale
A multiple marker screening, also known as a triple or quad screen, is performed during pregnancy to identify potential neural tube defects, such as spina bifida, and chromosomal abnormalities like Down syndrome. This test measures specific substances in the mother’s blood to assess the risk of these conditions.
Choice D rationale
Group B streptococcus (GBS) screening is performed to detect the presence of GBS bacteria in the mother’s body, not to determine the presence of sexually transmitted infections (STIs). GBS can cause serious infections in newborns, so it is important to identify and treat it before delivery.
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Correct Answer is ["F","G","H"]
Explanation
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal and do not indicate any immediate concern. Reflexes are graded on a scale from 0 to 4+, with 2+ being normal. A 1+ reflex is slightly diminished but can be normal in some individuals.
Choice B rationale:
A pain rating of 3 on a scale of 0 to 10 is relatively low and manageable. Postpartum pain is expected, and a rating of 3 does not indicate severe pain that requires immediate intervention.
Choice C rationale:
The blood pressure reading of 136/86 mm Hg is slightly elevated but not alarming. Postpartum blood pressure can fluctuate, and this reading does not indicate a hypertensive crisis.
Choice D rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common postpartum due to fluid retention and is not typically a cause for immediate concern unless accompanied by other symptoms such as severe pain or redness.
Choice E rationale:
Soft breasts with intact nipples are normal findings in the early postpartum period, especially if the client is breastfeeding. There is no indication of issues such as mastitis or engorgement.
Choice F rationale:
A large amount of lochia rubra is concerning as it may indicate postpartum hemorrhage. Lochia should gradually decrease in amount and change in color over time. A large amount of bright red blood suggests excessive bleeding that requires immediate follow-up.
Choice G rationale:
A soft uterine tone is abnormal and can indicate uterine atony, which is a leading cause of postpartum hemorrhage. The uterus should be firm and contracted to prevent excessive bleeding.
Choice H rationale:
Lateral deviation of the uterus can indicate a full bladder, which can prevent the uterus from contracting properly and lead to increased bleeding. This requires immediate attention to ensure the bladder is emptied and the uterus can contract effectively.
Correct Answer is B
Explanation
Choice A rationale
A large banana is not a significant source of dietary calcium. While bananas are nutritious and provide potassium and vitamin C, they do not contain enough calcium to meet the needs of a pregnant client who does not consume dairy products.
Choice B rationale
Kale is an excellent non-dairy source of calcium. Dark leafy greens like kale are rich in calcium, with approximately 90 mg of calcium per cup when cooked. Including kale in the diet can help pregnant women meet their calcium needs, especially if they do not consume dairy products.
Choice C rationale
A baked potato is not a significant source of dietary calcium. While potatoes provide several nutrients, including potassium and vitamin C, they do not contain enough calcium to be recommended as a primary source for a pregnant client who does not consume dairy products.
Choice D rationale
White corn is not a significant source of dietary calcium. While it can contribute to overall nutritional intake, it does not provide enough calcium to meet the needs of a pregnant client who does not consume dairy products.