The pregnant client tells the nurse that she thinks she is carrying tw

Maternal NCLEX

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Question 1 of 5.

The pregnant client tells the nurse that she thinks she is carrying twins. In reviewing the client's history and medical records, the nurse should determine that which factors are associated with a multiple gestation? Select all that apply.

A. Elevated serum alpha-fetoprotein

B. Use of reproductive technology

C. Maternal age greater than 40

D. History of twins in the family

E. Elevated hemoglobin levels

Explanation: An elevated serum alpha-fetoprotein level (an oncofetal protein normally produced by the fetal liver and yolk sac) is associated with a multiple gestation. The use of reproductive technology such as artificial insemination or fertility drugs is associated with a multiple gestation. History of twins in the family is associated with a multiple gestation. Maternal age greater than 40 is not associated with multiple gestation. An elevated Hgb is not associated with multiple gestation.

Question 2 of 5.

The nurse correctly explains that the bleeding is the result of sloughing of which structure?

A. Endometrium

B. Myometrium

C. Epimetrium

D. None of the above

Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.

Question 3 of 5.

On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?

A. 5 months

B. 6 months

C. 7 months

D. 8 months

Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.

Question 4 of 5.

The nurse correctly assists the client into which position?

A. Lithotomy

B. Prone

C. Sims'

D. Trendelenburg's

Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.

Question 5 of 5.

Which response by the nurse is most accurate?

A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.

B. Hepatitis B surface antigen (HBsAg) test can detect this defect.

C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.

D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.

Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.