NUR325-B-Nursing Services Childbearing- Final Exam B (CBU )

The correct answer is A:  BP 88/56

Explanation:

Nifedipine is a calcium channel blocker used to relax uterine muscles and suppress preterm labor. It works by inhibiting calcium from entering smooth muscle cells, which reduces uterine contractions. However, it also causes vasodilation, which can lower blood pressure. A blood pressure of 88/56 is considered hypotension, and administering nifedipine could further lower blood pressure, leading to dizziness, fainting, or inadequate blood flow to the mother and fetus.

Why the other options are incorrect:

B. Ruptured membranes:

Nifedipine may still be used with ruptured membranes to delay labor if the benefits outweigh the risks. While ruptured membranes increase the risk of infection, nifedipine does not directly affect the amniotic sac or increase infection risk.

C. Temperature 101:

A temperature of 101°F (38.3°C) suggests a possible infection (e.g., chorioamnionitis), which needs evaluation. However, this is not a direct contraindication to nifedipine. The nurse should monitor the patient for signs of infection but would not automatically question the nifedipine order based on temperature alone.

D. Pulse 122:

An elevated pulse is a common side effect of nifedipine due to vasodilation. While the nurse should monitor the patient's heart rate, a pulse of 122 bpm is not a strict contraindication unless it worsens or other symptoms of cardiovascular instability appear.

Summary:

The nurse would question the nifedipine order due to the patient's low blood pressure (88/56) because the medication may further lower BP and compromise maternal and fetal circulation. Other factors, like ruptured membranes, fever, or increased pulse, do not directly prevent the use of nifedipine in preterm labor but require close monitoring.

The correct answer is C: His head is normal for his gestational age, his body is small making it look larger.

Explanation:

C. His head is normal for his gestational age, his body is small making it look larger.: The correct response is to reassure the father by explaining that the infant’s head size is likely normal for his gestational age, but because the body is small, the head may appear larger in proportion. This phenomenon is known as relative macrocephaly, which can occur in small-for-gestational-age (SGA) infants. In this case, the infant's birth weight of 2400 gm places him on the smaller side for a full-term infant (37 weeks), and the head may appear more prominent as a result. This is generally not a cause for concern, unless other signs or symptoms suggest a neurological issue.

Why the Other Options Are Incorrect:

A. Have you discussed your concerns with your doctor?: While it is important to encourage communication with the physician, this response does not directly address the father's concern. The father is seeking immediate reassurance and explanation. A more informative answer would be appropriate in this situation, providing a response based on the infant's condition rather than redirecting him to the doctor.

B. He may have hydrocephalus, but don't worry that can be corrected with a shunt.: This answer is not appropriate because it introduces unnecessary worry. While hydrocephalus could cause a large head, this is not likely the cause in this situation, given the infant's gestational age and weight. It would be premature and potentially alarming to suggest this possibility without further evaluation. The infant's large head is more likely a normal feature for his size, and hydrocephalus would require additional clinical signs to be suspected.

D. You shouldn't be concerned about his head. Be concerned about his weight.: This response downplays the father's valid concern about his infant's head and diverts attention from the issue in a dismissive way. While concerns about weight are important, the father's specific concern about the head should be addressed first. It’s essential to acknowledge his observation and provide a clear and reassuring explanation.

Summary:

The best response is C. His head is normal for his gestational age, his body is small making it look larger. This addresses the father’s concern in a reassuring and informative manner, explaining the likely reason for the proportionally large head in an infant who is small for gestational age. Other responses either redirect the father unnecessarily, introduce concerns about conditions like hydrocephalus, or dismiss his worry without addressing it effectively.

The correct answer is A: Protein

Explanation:

In clients with preeclampsia, increasing protein intake is essential because protein helps to maintain oncotic pressure, which prevents fluid leakage from blood vessels into tissues. Preeclampsia is associated with proteinuria (loss of protein in the urine), edema, and hypertension, so replacing lost protein through the diet is vital to support vascular integrity and reduce fluid retention. Additionally, adequate protein supports fetal growth and maternal tissue repair.

Why the other options are incorrect:

B. Folic Acid:

While folic acid is crucial for neural tube development early in pregnancy, increasing it will not address the primary concerns in preeclampsia (such as hypertension, proteinuria, and edema). Folic acid does not counteract the protein loss that occurs in preeclampsia.

C. Carbohydrates:

Although carbohydrates provide energy, an increase in carbohydrates is not specifically recommended for preeclampsia. Excessive carbohydrate intake can contribute to weight gain and fluid retention, which can worsen symptoms.

D. Fats:

While healthy fats are part of a balanced diet, increasing fats is not beneficial for managing preeclampsia. High-fat diets can exacerbate cardiovascular risks and contribute to poor circulation, which is already compromised in preeclampsia.

Summary:

The nurse should instruct the client with preeclampsia to increase protein intake to compensate for protein loss, maintain oncotic pressure, and reduce edema. Other nutrients are important for general pregnancy health, but protein is specifically critical to manage and mitigate the effects of preeclampsia.

Correct anwer D: Tubal damage from PID.

Explanation:

The most likely cause of infertility in this patient is tubal damage from pelvic inflammatory disease (PID). PID is an infection of the upper reproductive tract (including the uterus, fallopian tubes, and ovaries) that can result from sexually transmitted infections (STIs) like chlamydia or gonorrhea. This condition can cause inflammation, scarring, and blockage of the fallopian tubes, preventing the egg from meeting the sperm, which leads to infertility. Studies show that up to 20% of women with a history of PID may experience infertility due to tubal factor damage.

Why the Other Options Are Incorrect:

A. Tubal damage from hyperglycemia:

While uncontrolled diabetes can affect hormonal balance and ovulation, it does not directly cause tubal damage. There is no evidence that hyperglycemia leads to physical injury of the fallopian tubes.

B. Tubal damage from migraine headaches:

Migraines are neurological in origin and do not impact reproductive anatomy. They have no direct effect on fallopian tube function or fertility. Although migraines can cause discomfort, they do not lead to tubal scarring or blockage.

C. Tubal damage from fibromyalgia:

Fibromyalgia is a chronic pain condition characterized by widespread musculoskeletal pain and fatigue, but it does not cause tubal damage. This condition does not interfere with reproductive organs or fallopian tube integrity.

Summary:

The correct answer is D. Tubal damage from PID because pelvic inflammatory disease is a known and common cause of tubal infertility due to inflammation, scarring, and blockage of the fallopian tubes. The other options do not cause structural damage to the fallopian tubes and are therefore not likely reasons for infertility.

The correct answer is C: A woman who wishes to start a family in the next two months

Explanation:

C. A woman who wishes to start a family in the next two months: This is the correct answer because the copper intrauterine device (IUD) is designed for long-term contraception — up to 10 years of highly effective, hormone-free pregnancy prevention. While it can be removed at any time with a rapid return to fertility, inserting a copper IUD in someone who plans to conceive in just a few weeks is not clinically ideal. The benefits of IUD use outweigh the risks for those seeking longer-term contraception, but in this case, it would be unnecessarily invasive for such a short timeframe. A short-acting method, such as condoms or progestin-only pills, may be more appropriate for women planning pregnancy in the near future.

Why the Other Options Are Incorrect:

A. A woman who has just been victim of rape: This is a very appropriate candidate for a copper IUD. In fact, the copper IUD is one of the most effective forms of emergency contraception if inserted within 5 days of unprotected intercourse, including in cases of sexual assault. It provides both immediate pregnancy prevention and ongoing contraception, making it a valuable option for this scenario.

B. A 35-year-old smoker who is G5P3023: This is also an appropriate candidate. The copper IUD contains no hormones, so smoking — which is a major concern when considering estrogen-containing contraceptives — is not a contraindication. The woman’s obstetric history (G5P3023) indicates multiple full-term pregnancies, which makes IUD placement technically easier and often more acceptable to the patient. Therefore, she is a good candidate.

D. A 42-year-old woman in a long-term monogamous relationship: This woman is an excellent candidate for a copper IUD. She is likely seeking a long-term, low-maintenance contraceptive method, and assuming she is at low risk for sexually transmitted infections (due to the monogamous relationship), the copper IUD is both safe and effective. Age itself is not a contraindication; in fact, IUDs are often recommended for women over 35 who no longer desire pregnancy.

Summary:

The only poor candidate for a copper IUD among the listed options is C. A woman who wishes to start a family in the next two months. While the copper IUD does not delay fertility after removal, its use is best suited for those needing long-term contraception. The other choices — a rape victim seeking emergency contraception, a 35-year-old smoker with prior pregnancies, and a 42-year-old woman in a stable relationship — all represent ideal candidates for copper IUD use based on safety, effectiveness, and reproductive goals.

The correct answer is A: Kernicterus

Explanation:

A. Kernicterus: This is the primary concern when a newborn has a serum bilirubin level of 28 mg/dL, which is critically high and places the infant at immediate risk for bilirubin encephalopathy. Kernicterus is a form of brain damage caused by the deposition of unconjugated bilirubin in the brain tissues, particularly in the basal ganglia and brainstem nuclei. Symptoms of kernicterus may include lethargy, hypotonia, high-pitched cry, poor feeding, seizures, and eventually long-term neurological deficits such as cerebral palsy, sensorineural hearing loss, and developmental delays. Bilirubin levels above 25 mg/dL are considered an emergency and require immediate intervention, such as exchange transfusion and intensive phototherapy. Therefore, this is the most urgent and primary concern.

Why the other options are incorrect:

B. Absence of DTRs (Deep Tendon Reflexes): While absent reflexes can be a sign of neurologic involvement in kernicterus, it is not the primary concern—rather, it is a possible symptom of kernicterus. Therefore, it is not the central issue but a secondary manifestation. The nurse should focus first on the life-threatening condition of kernicterus rather than a single symptom.

C. Hematoma: Cephalohematomas and other birth-related hematomas can contribute to increased bilirubin levels due to the breakdown of red blood cells in the trapped blood. However, in this case, the hematoma is not the primary concern—the extreme bilirubin level and the risk of brain damage are. A hematoma may be a contributing factor, but it is not the nurse's immediate concern with a bilirubin of 28 mg/dL.

D. Dehydration symptoms: Dehydration can contribute to the reduced excretion of bilirubin, worsening jaundice. However, like hematoma, this is a contributing factor, not the most urgent risk. In a newborn with critically high bilirubin, the focus should be on preventing permanent neurological damage, not on dehydration alone.

Summary: The nurse’s primary concern for a newborn with a serum bilirubin level of 28 mg/dL is kernicterus, a life-threatening and irreversible neurological condition. While absent reflexes, hematomas, and dehydration may be contributing signs or factors, they are not the most immediate threat. The priority is to prevent bilirubin-induced brain injury through urgent treatment.

The correct answer is C: alpha-fetoprotein

Explanation for the correct answer: When a neural tube defect (NTD) is suspected, alpha-fetoprotein (AFP) levels in the maternal blood are measured. AFP is a protein produced by the fetal liver, and it is present in both the maternal blood and amniotic fluid. Elevated levels of AFP in maternal serum can be indicative of conditions such as neural tube defects (e.g., spina bifida or anencephaly) because the defective neural tube allows AFP to leak into the amniotic fluid, which then enters the maternal bloodstream. This test is typically done in the second trimester as part of prenatal screening.

Why the other options are wrong:

A) Estrogen: Estrogen is a hormone produced by the placenta and ovaries during pregnancy, but it is not used to detect neural tube defects. Estrogen levels fluctuate throughout pregnancy and are more commonly monitored to assess placental function and fetal well-being, but they are not associated with detecting neural tube defects.

B) Progesterone: Progesterone is another hormone that is important for maintaining pregnancy, but it is not used to diagnose or screen for neural tube defects. It plays a role in supporting the uterine lining but is not an indicator of fetal neural development.

D) Luteinizing hormone: Luteinizing hormone (LH) is involved in the regulation of the menstrual cycle and ovulation, and its levels are measured in fertility assessments, but it has no role in screening or diagnosing neural tube defects.

Summary: The substance measured in maternal blood when a neural tube defect is suspected is alpha-fetoprotein (AFP). Elevated levels of AFP can indicate the presence of a neural tube defect, making it an important biomarker in prenatal screening. The other substances listed (estrogen, progesterone, and luteinizing hormone) are not used for this purpose.

The correct answer is C: January 22

Explanation:

Naegle’s Rule is used to estimate a pregnant person's due date (estimated date of delivery or EDD). The formula is:

Take the first day of the last menstrual period (LMP).

Subtract three months from the month.

Add seven days to the day.

Adjust the year if necessary.

For this patient:

LMP: April 15

Subtract 3 months → January 15

Add 7 days → January 22

Thus, the estimated due date is January 22.

The correct answer is C: You are not a candidate for external version because you have a placenta previa.

Explanation:

An external cephalic version (ECV) is a procedure in which a healthcare provider manually attempts to turn a breech or transverse fetus into a head-down (cephalic) position before delivery. However, placenta previa is an absolute contraindication for an external version.

Placenta previa occurs when the placenta partially or completely covers the cervix, increasing the risk of severe hemorrhage during labor or any procedures that put pressure on the uterus, such as an external version. Because of this, a C-section is the recommended delivery method for placenta previa.

Why the Other Options Are Incorrect:

A. You are a great candidate for external version. We will schedule it for this week.

This is incorrect because the client is not a candidate for external version due to the placenta previa. Attempting an ECV could cause placental abruption, heavy bleeding, and fetal distress, making it unsafe.

B. You will have to be in active labor before we do an external version.

This is incorrect because an external version is not performed during active labor. It is typically done before labor begins (usually between 36-37 weeks for nulliparous women and 37+ weeks for multiparous women). More importantly, this patient is not a candidate at all due to placenta previa.

D. You are not a candidate for external version because your baby is in a breech presentation.

This is incorrect because having a breech presentation is actually the reason why an external version is done. The goal of the procedure is to turn the fetus from breech to cephalic. However, this patient cannot have the procedure due to placenta previa, not because of the breech presentation itself.

Summary:

The best answer is "You are not a candidate for external version because you have a placenta previa." Placenta previa is a contraindication for external version because of the high risk of severe bleeding and fetal distress. The correct management for a patient with placenta previa at 36 weeks with a breech presentation is a scheduled cesarean delivery.