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?
The results can indicate a genetic disorder.
This test determines how well my placenta is functioning.
This test is done if there is a risk of an Rh incompatibility.
The results will show if my baby's lungs are mature.
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 A
Explanation
Choice A rationale
Respiratory rate of 10/min is a critical adverse effect, indicating potential respiratory depression due to magnesium sulfate, a serious and life-threatening condition requiring immediate intervention.
Choice B rationale
Urine output of 160 mL in 4 hours is lower than expected but not immediately life-threatening. It needs monitoring but is not as critical as respiratory rate.
Choice C rationale
Diaphoresis, or excessive sweating, can be a side effect of magnesium sulfate but is not life-threatening. It warrants attention but does not require immediate reporting.
Choice D rationale
Nausea is a common, less severe side effect of magnesium sulfate that does not indicate an urgent situation.
Correct Answer is C
Explanation
Choice A rationale
Starting each feeding with the same breast can lead to engorgement and decreased milk supply in the other breast.
Choice B rationale
Exclusive breastfeeding is recommended for the first six months. Providing a formula supplement can interfere with milk supply and breastfeeding success.
Choice C rationale
Allowing the newborn to empty the first breast ensures they receive hindmilk, which is richer in fat and essential for growth.
Choice D rationale
Newborns do not need additional water as breast milk or formula provides all necessary hydration.