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A nurse is reinforcing teaching with a client who is undergoing amniotic fluid assessment for the lecithin/sphingomyelin ratio. Which of the following client statements indicates an understanding of the teaching?

A.

The results can indicate a genetic disorder.

B.

This test determines how well my placenta is functioning.

C.

This test is done if there is a risk of an Rh incompatibility.

D.

The results will show if my baby's lungs are mature.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Lecithin/sphingomyelin (L/S) ratio does not indicate genetic disorders; it's used to assess fetal lung maturity.

 

Choice B rationale

 

The test does not determine placental function. It specifically evaluates fetal lung maturity through the ratio of lecithin to sphingomyelin in amniotic fluid.

 

Choice C rationale

 

The test is not used to assess the risk of Rh incompatibility. The L/S ratio focuses on lung development rather than blood compatibility issues.

 

Choice D rationale

 

The L/S ratio assesses the baby's lung maturity, indicating if the lungs produce enough surfactant for proper function after birth.

 


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Correct Answer is C

Explanation

Choice A rationale

A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.

Choice B rationale

Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.

Choice C rationale

This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.

Choice D rationale

An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .

Correct Answer is B

Explanation

Choice A rationale

Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.

Choice B rationale

Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.

Choice C rationale

Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.

Choice D rationale

Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.

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