The nurse is reviewing maternal serum alpha-fetoprotein (MSAFP) results. Which conditions are associated with elevated levels of MSAFP? (Select all that apply.)
a. Fetal demise
b. Neural tube defects
c. Abdominal wall defects
d. Chromosomal trisomies
e. Gestational trophoblastic disease
ANS: A, B, C
Elevated levels of AFP may indicate open neural tube defects (e.g., anencephaly, spina bifida), abdominal wall defects (e.g., omphalocele, gastroschisis), or fetal demise. Low levels of AFP may indicate chromosomal trisomies (e.g., Down syndrome, trisomy 21) or gestational trophoblastic disease.
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The nurse assists a health care provider with the collection of cerebrospinal fluid via a lumbar puncture. Which would not be included in the nurse's documentation of this procedure?
1. Specimen collection and disposition 2. Health care provider's contamination of first needle, requiring the nurse to obtain a second needle 3. Client response during and after the procedure 4. Sterile technique followed throughout the collection process
The nurse is conducting an assessment on an older adult client who is confused. The client is accompanied to the appointment with an adult child. When collecting data, who can provide primary sources of data during the assessment?
A) The confused older adult client. B) The client's adult child. C) The nurse who cares for the client at the retirement home. D) The primary healthcare provider.
The nurse is caring for a client who is being seen for sunburn. What should the nurse include in education to prevent this from occurring in the future?
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