Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A pregnant woman undergoes a triple/quadruple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's alpha-fetoprotein (AFP) level is decreased?
A. Sickle-cell anemia
Reason: This is incorrect because sickle-cell anemia is a genetic disorder that affects the shape and function of the red blood cells. It is not related to the AFP level, which is a protein produced by the fetal liver and yolk sac.
B. Cardiac defects
Reason: This is incorrect because cardiac defects are abnormalities in the structure or function of the heart. They are not related to the AFP level, which is a marker of neural tube defects and abdominal wall defects.
C. Down syndrome
Reason: This is correct because Down syndrome is a chromosomal disorder that results from an extra copy of chromosome 21. It is associated with a decreased AFP level, as well as increased levels of human chorionic gonadotropin (hCG) and unconjugated estriol (uE3).
D. Respiratory disorders
Reason: This is incorrect because respiratory disorders are problems that affect the lungs and breathing. They are not related to the AFP level, which reflects the fetal development and integrity.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn 4 Proctored Exam. Take the full exam now
Full Explanation
Choice A Reason: This is incorrect because sickle-cell anemia is a genetic disorder that affects the shape and function of the red blood cells. It is not related to the AFP level, which is a protein produced by the fetal liver and yolk sac.
Choice B Reason: This is incorrect because cardiac defects are abnormalities in the structure or function of the heart. They are not related to the AFP level, which is a marker of neural tube defects and abdominal wall defects.
Choice C Reason: This is correct because Down syndrome is a chromosomal disorder that results from an extra copy of chromosome 21. It is associated with a decreased AFP level, as well as increased levels of human chorionic gonadotropin (hCG) and unconjugated estriol (uE3).
Choice D Reason: This is incorrect because respiratory disorders are problems that affect the lungs and breathing. They are not related to the AFP level, which reflects the fetal development and integrity.
Similar Questions
Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?
A. Ferrous sulfate
Reason: This is incorrect because ferrous sulfate is an iron supplement that is used to treat or prevent iron-deficiency anemia. It has no effect on magnesium sulfate, which is a medication that lowers blood pressure and prevents seizures in severe preeclampsia.
B. Potassium chloride
Reason: This is incorrect because potassium chloride is an electrolyte supplement that is used to treat or prevent low levels of potassium in the blood. It has no effect on magnesium sulfate, which can cause hypermagnesemia, or high levels of magnesium in the blood.
C. Calcium carbonate
Reason: This is incorrect because calcium carbonate is an antacid that is used to treat or prevent heartburn, indigestion, or calcium deficiency. It has no effect on magnesium sulfate, which can cause hypocalcemia, or low levels of calcium in the blood.
D. Calcium gluconate
Reason: This is correct because calcium gluconate is an antidote that is used to treat magnesium toxicity, which can occur when magnesium sulfate is given in high doses or for prolonged periods. Calcium gluconate reverses the effects of magnesium sulfate on the neuromuscular and cardiovascular systems, such as muscle weakness, respiratory depression, cardiac arrhythmias, or cardiac arrest.
Full Explanation
Choice A Reason: This is incorrect because ferrous sulfate is an iron supplement that is used to treat or prevent iron-deficiency anemia. It has no effect on magnesium sulfate, which is a medication that lowers blood pressure and prevents seizures in severe preeclampsia.
Choice B Reason: This is incorrect because potassium chloride is an electrolyte supplement that is used to treat or prevent low levels of potassium in the blood. It has no effect on magnesium sulfate, which can cause hypermagnesemia, or high levels of magnesium in the blood.
Choice C Reason: This is incorrect because calcium carbonate is an antacid that is used to treat or prevent heartburn, indigestion, or calcium deficiency. It has no effect on magnesium sulfate, which can cause hypocalcemia, or low levels of calcium in the blood.
Choice D Reason: This is correct because calcium gluconate is an antidote that is used to treat magnesium toxicity, which can occur when magnesium sulfate is given in high doses or for prolonged periods. Calcium gluconate reverses the effects of magnesium sulfate on the neuromuscular and cardiovascular systems, such as muscle weakness, respiratory depression, cardiac arrhythmias, or cardiac arrest.
A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.
A. Ultrasound visualization of the fetus
Choice A Reason: This is incorrect because ultrasound visualization of the fetus is a positive sign of pregnancy, not a probable sign. A positive sign of pregnancy is a direct and definitive evidence of the presence of a fetus, such as fetal movement felt by the examiner or fetal heart sounds heard by a Doppler device.
B. Softening of the cervix
Choice B Reason: This is correct because softening of the cervix, also known as Goodell's sign, is a probable sign of pregnancy. A probable sign of pregnancy is a strong indication of pregnancy based on physical changes in the reproductive organs, such as enlargement of the uterus or changes in the shape and consistency of the cervix.
C. Positive pregnancy test
Choice C Reason: This is correct because a positive pregnancy test, which detects human chorionic gonadotropin (hCG) in urine or blood, is a probable sign of pregnancy. However, it is not a conclusive sign, as hCG can also be produced by other conditions such as ectopic pregnancy, molar pregnancy, or trophoblastic tumors.
D. Absence of menstruation
Choice D Reason: This is correct because absence of menstruation, also known as amenorrhea, is a probable sign of pregnancy. It occurs when ovulation and menstruation cease due to hormonal changes during pregnancy. However, it is not a definitive sign, as amenorrhea can also be caused by other factors such as stress, illness, or hormonal imbalances.
E. Ballottement
Choice E Reason: This is correct because ballottement, which is a rebounding of the fetus against the examiner's fingers during a pelvic examination, is a probable sign of pregnancy. It can be felt around 16 to 20 weeks of gestation.
F. Auscultation of a fetal heart beat
Choice F Reason: This is incorrect because auscultation of a fetal heart beat, which can be heard by a fetoscope around 18 to 20 weeks of gestation or by a Doppler device around 10 to 12 weeks of gestation, is a positive sign of pregnancy, not a probable sign.
Full Explanation
Choice A Reason: This is incorrect because ultrasound visualization of the fetus is a positive sign of pregnancy, not a probable sign. A positive sign of pregnancy is a direct and definitive evidence of the presence of a fetus, such as fetal movement felt by the examiner or fetal heart sounds heard by a Doppler device.
Choice B Reason: This is correct because softening of the cervix, also known as Goodell's sign, is a probable sign of pregnancy. A probable sign of pregnancy is a strong indication of pregnancy based on physical changes in the reproductive organs, such as enlargement of the uterus or changes in the shape and consistency of the cervix.
Choice C Reason: This is correct because a positive pregnancy test, which detects human chorionic gonadotropin (hCG) in urine or blood, is a probable sign of pregnancy. However, it is not a conclusive sign, as hCG can also be produced by other conditions such as ectopic pregnancy, molar pregnancy, or trophoblastic tumors.
Choice D Reason: This is correct because absence of menstruation, also known as amenorrhea, is a probable sign of pregnancy. It occurs when ovulation and menstruation cease due to hormonal changes during pregnancy. However, it is not a definitive sign, as amenorrhea can also be caused by other factors such as stress, illness, or hormonal imbalances.
Choice E Reason: This is correct because ballottement, which is a rebounding of the fetus against the examiner's fingers during a pelvic examination, is a probable sign of pregnancy. It can be felt around 16 to 20 weeks of gestation.
Choice F Reason: This is incorrect because auscultation of a fetal heart beat, which can be heard by a fetoscope around 18 to 20 weeks of gestation or by a Doppler device around 10 to 12 weeks of gestation, is a positive sign of pregnancy, not a probable sign.
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?
A. Marijuana
Reason: This is incorrect because marijuana is a psychoactive substance that affects the central nervous system and can cause euphoria, relaxation, altered perception, and impaired memory. It does not cause tachycardia, hypertension, or vasoconstriction in pregnant women or their fetuses.
B. Cocaine
Reason: This is correct because cocaine is a stimulant substance that affects the cardiovascular system and can cause tachycardia, hypertension, vasoconstriction, arrhythmias, and ischemia in pregnant women or their fetuses. It can also increase the risk of placental abruption, preterm labor, intrauterine growth restriction, and fetal death.
C. Nicotine
Reason: This is incorrect because nicotine is a stimulant substance that affects the respiratory system and can cause bronchodilation, increased heart rate, and increased blood pressure in pregnant women or their fetuses. However, it does not cause vasoconstriction, but rather vasodilation.
D. Caffeine
Reason: This is incorrect because caffeine is a stimulant substance that affects the central nervous system and can cause alertness, insomnia, anxiety, and increased urine output in pregnant women or their fetuses. It does not cause tachycardia, hypertension, or vasoconstriction in moderate doses.
E. Heroin
Choice E Reason: This is incorrect because heroin is an opioid substance that affects the central nervous system and can cause euphoria, sedation, analgesia, and respiratory depression in pregnant women or their fetuses. It does not cause tachycardia, hypertension, or vasoconstriction.
Full Explanation
Choice A Reason: This is incorrect because marijuana is a psychoactive substance that affects the central nervous system and can cause euphoria, relaxation, altered perception, and impaired memory. It does not cause tachycardia, hypertension, or vasoconstriction in pregnant women or their fetuses.
Choice B Reason: This is correct because cocaine is a stimulant substance that affects the cardiovascular system and can cause tachycardia, hypertension, vasoconstriction, arrhythmias, and ischemia in pregnant women or their fetuses. It can also increase the risk of placental abruption, preterm labor, intrauterine growth restriction, and fetal death.
Choice C Reason: This is incorrect because nicotine is a stimulant substance that affects the respiratory system and can cause bronchodilation, increased heart rate, and increased blood pressure in pregnant women or their fetuses. However, it does not cause vasoconstriction, but rather vasodilation.
Choice D Reason: This is incorrect because caffeine is a stimulant substance that affects the central nervous system and can cause alertness, insomnia, anxiety, and increased urine output in pregnant women or their fetuses. It does not cause tachycardia, hypertension, or vasoconstriction in moderate doses.
Choice E Reason: This is incorrect because heroin is an opioid substance that affects the central nervous system and can cause euphoria, sedation, analgesia, and respiratory depression in pregnant women or their fetuses. It does not cause tachycardia, hypertension, or vasoconstriction.
