Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is discussing the risks associated with a Contraction Stress Test (CST) with a pregnant client.
Which complication should the nurse mention?
A. Preterm labor.
A contraction stress test (CST) is a test that simulates labor contractions to see how the baby’s heart rate responds to the stress of uterine contractions. The biggest risk of the test is that it may cause the pregnant person to go into labor before their due date.
B. Premature rupture of membranes.
This is a condition where the amniotic sac breaks before labor begins. It can increase the risk of infection and cord prolapse, but it is not a direct complication of CST.
C. Infection.
This is a possible risk of any invasive procedure, but CST is usually done with external fetal monitoring and oxytocin infusion, which do not require breaking the skin or entering the uterus.
D. Bleeding.
This is a potential risk of CST for people who have placenta previa, a condition where the placenta covers the cervix and can detach during contractions. However, CST is not recommended for people who have placenta previa or other conditions that increase the risk of uterine rupture or bleeding.
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Full Explanation
A contraction stress test (CST) is a test that simulates labor contractions to see how the baby’s heart rate responds to the stress of uterine contractions.
The biggest risk of the test is that it may cause the pregnant person to go into labor before their due date.
Some possible explanations for the other choices are:
Choice B. Premature rupture of membranes.
This is a condition where the amniotic sac breaks before labor begins.
It can increase the risk of infection and cord prolapse, but it is not a direct complication of CST.
Choice C. Infection.
This is a possible risk of any invasive procedure, but CST is usually done with external fetal monitoring and oxytocin infusion, which do not require breaking the skin or entering the uterus.
Choice D. Bleeding.
This is a potential risk of CST for people who have placenta previa, a condition where the placenta covers the cervix and can detach during contractions.
However, CST is not recommended for people who have placenta previa or other conditions that increase the risk of uterine rupture or bleeding.
Similar Questions
A client is scheduled for an abdominal ultrasound in two weeks to assess fetal growth and development during pregnancy.
Which of these statements made by the client indicates that further teaching is needed?
A. “I will drink plenty of fluids before my appointment.”
The client should drink plenty of fluids before an appointment for an abdominal ultrasound because it helps to fill the bladder and push the uterus up for better visualization.
B. “I will eat a light meal before my appointment.”
The client should not eat a light meal before an abdominal ultrasound because it can interfere with the quality of the images. The client should fast for 8 to 12 hours before the procedure. Normal ranges for fetal growth and development during pregnancy vary depending on the gestational age, but some general parameters are: Fetal heart rate: 110 to 160 beats per minute Biparietal diameter: 2.4 to 9.5 cm Crown-rump length: 0.8 to 8.4 cm Femur length: 1.0 to 7.8 cm Abdominal circumference: 9.4 to 35.6 cm
C. “I will wear comfortable clothing.”
The client should wear comfortable clothing that can be easily removed or lifted up to expose the abdomen.
D. “I will arrive at my appointment with a full bladder."
The client should arrive at the appointment with a full bladder because it acts as an acoustic window and improves the quality of the ultrasound images.
Full Explanation
The client should not eat a light meal before an abdominal ultrasound because it can interfere with the quality of the images.
The client should fast for 8 to 12 hours before the procedure.
Some additional information about the other choices are:
Choice A is correct.
The client should drink plenty of fluids before an appointment for an abdominal ultrasound because it helps to fill the bladder and push the uterus up for better visualization.
Choice C is correct.
The client should wear comfortable clothing that can be easily removed or lifted up to expose the abdomen.
Choice D is correct.
The client should arrive at the appointment with a full bladder because it acts as an acoustic window and improves the quality of the ultrasound images.
Normal ranges for fetal growth and development during pregnancy vary depending on the gestational age, but some general parameters are:
Fetal heart rate: 110 to 160 beats per minute
Biparietal diameter: 2.4 to 9.5 cm
Crown-rump length: 0.8 to 8.4 cm
Femur length: 1.0 to 7.8 cm
Abdominal circumference: 9.4 to 35.6 cm
A nurse is teaching about fetal development to a group of clients in the antenatal clinic.
Which of the following statements should the nurse include in the teaching?
A. “The baby’s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy.”
The baby’s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy. This is a device that uses sound waves to create an image of the baby’s heart and measure its rate and rhythm.
B. “The baby’s sex can be determined by ultrasound at 8 weeks of pregnancy.”
The baby’s sex cannot be determined by ultrasound at 8 weeks of pregnancy. The external genitalia are not fully developed until around 14 to 16 weeks of pregnancy. Even then, the accuracy of ultrasound depends on factors such as the position of the baby, the quality of the equipment, and the skill of the sonographer.
C. “The baby’s lungs are fully mature by 24 weeks of pregnancy.”
The baby’s lungs are not fully mature by 24 weeks of pregnancy. The lungs are one of the last organs to develop in the fetus and they continue to grow and mature until near term. The production of surfactant, a substance that helps the lungs expand and prevent collapse, begins around 24 weeks but is not sufficient until around 34 to 36 weeks.
D. “The baby’s eyes open and close by 16 weeks of pregnancy.”
The baby’s eyes do not open and close by 16 weeks of pregnancy. The eyelids are fused together until around 26 to 28 weeks of pregnancy, when they start to open and close periodically. The baby can also respond to light and dark stimuli around this time.
Full Explanation
The baby’s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy.
This is a device that uses sound waves to create an image of the baby’s heart and measure its rate and rhythm.
Some possible explanations for the other choices are:
Choice B is wrong because the baby’s sex can not be determined by ultrasound at 8 weeks of pregnancy.
The external genitalia are not fully developed until around 14 to 16 weeks of pregnancy.
Even then, the accuracy of ultrasound depends on factors such as the position of the baby, the quality of the equipment, and the skill of the sonographer.
Choice C is wrong because the baby’s lungs are not fully mature by 24 weeks of pregnancy.
The lungs are one of the last organs to develop in the fetus and they continue to grow and mature until near term.
The production of surfactant, a substance that helps the lungs expand and prevent collapse, begins around 24 weeks but is not sufficient until around 34 to 36 weeks.
Choice D is wrong because the baby’s eyes do not open and close by 16 weeks of pregnancy.
The eyelids are fused together until around 26 to 28 weeks of pregnancy, when they start to open and close periodically.
The baby can also respond to light and dark stimuli around this time.
A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation.
The nurse provides which of the following explanations about this test to the client?
A. It is a diagnostic test for spinal defects in the fetus.
The MSAFP test is not a diagnostic test. It only indicates the probability of having a spinal defect, but it does not confirm or rule out the condition. A diagnostic test, such as an ultrasound or amniocentesis, is needed to make a definitive diagnosis.
B. It is a screening test for spinal defects in the fetus.
"It is a screening test for spinal defects in the fetus." The MSAFP test is a blood test that measures the amount of alpha-fetoprotein (AFP) in the mother’s blood. AFP is a protein produced by the baby during pregnancy. The test helps to assess the baby’s risk of certain birth defects, such as neural tube defects, which are abnormalities in the development of the brain and spine. The normal range of MSAFP levels varies depending on the gestational age of the baby and the laboratory methods used. Generally, the MSAFP levels increase until about 15 weeks of pregnancy and then decrease until delivery. The average MSAFP level at 15 weeks of pregnancy is about 38 ng/mL. However, different laboratories may have different reference ranges, so it is important to consult your healthcare provider for your specific results and interpretation.
C. It is a diagnostic test for chromosomal abnormalities in the fetus.
The MSAFP test is not a diagnostic test for chromosomal abnormalities either. It only indicates the probability of having a chromosomal abnormality, such as Down syndrome, but it does not confirm or rule out the condition. A diagnostic test, such as a chorionic villus sampling (CVS) or amniocentesis, is needed to make a definitive diagnosis.
D. It is a screening test for chromosomal abnormalities in the fetus.
This statement is partially correct, but not the best answer. The MSAFP test alone is not very accurate for screening chromosomal abnormalities. It is usually combined with other blood tests and an ultrasound to form a more reliable screening test called a quad screen or an integrated screen.
Full Explanation
"It is a screening test for spinal defects in the fetus."
The MSAFP test is a blood test that measures the amount of alpha-fetoprotein (AFP) in the mother’s blood.
AFP is a protein produced by the baby during pregnancy. The test helps to assess the baby’s risk of certain birth defects, such as neural tube defects, which are abnormalities in the development of the brain and spine.
A. “It is a diagnostic test for spinal defects in the fetus.” This statement is wrong because the MSAFP test is not a diagnostic test.
It only indicates the probability of having a spinal defect, but it does not confirm or rule out the condition. A diagnostic test, such as an ultrasound or amniocentesis, is needed to make a definitive diagnosis.
C. “It is a diagnostic test for chromosomal abnormalities in the fetus.” This statement is wrong because the MSAFP test is not a diagnostic test for chromosomal abnormalities either.
It only indicates the probability of having a chromosomal abnormality, such as Down syndrome, but it does not confirm or rule out the condition. A diagnostic test, such as a chorionic villus sampling (CVS) or amniocentesis, is needed to make a definitive diagnosis.
D. “It is a screening test for chromosomal abnormalities in the fetus.” This statement is partially correct, but not the best answer.
The MSAFP test alone is not very accurate for screening chromosomal abnormalities. It is usually combined with other blood tests and an ultrasound to form a more reliable screening test called a quad screen or an integrated screen.
The normal range of MSAFP levels varies depending on the gestational age of the baby and the laboratory methods used. Generally, the MSAFP levels increase until about 15 weeks of pregnancy and then decrease until delivery. The average MSAFP level at 15 weeks of pregnancy is about 38 ng/mL. However, different laboratories may have different reference ranges, so it is important to consult your healthcare provider for your specific results and interpretation.