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 ["B","F","G"]
Explanation
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.
Choice B rationale:
Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.
Choice C rationale:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.
Choice D rationale:
A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.
Choice E rationale:
Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.
Choice F rationale:
A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.
Choice G rationale:
A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.
Choice H rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.
Correct Answer is ["C","E"]
Explanation
Choice A rationale
Douching is generally not recommended, especially during pregnancy, because it can disrupt the natural balance of bacteria in the vagina, potentially leading to infections or other complications.
Choice B rationale
Avoiding urination at bedtime is not advisable, as holding in urine can increase the risk of urinary tract infections (UTIs). Frequent urination is a good practice to help prevent and manage UTIs.
Choice C rationale
Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections and irritation.
Choice D rationale
Eliminating yogurt products from the diet is not necessary; in fact, yogurt contains probiotics that can be beneficial for maintaining a healthy balance of bacteria in the gut and vaginal area.
Choice E rationale
Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.