A nurse is assisting with the care of a client who is 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

Assist the client into a supine position.

Explain that nonreactivity might require immediate medication administration.

Remind the client to press the button when she feels fetal movement.

Tell the client the test should take about 10 min.

Answer and Explanation

The Correct Answer is C

A. Assist the client into a supine position is incorrect. A supine position can reduce uterine blood flow and may lead to hypotension. The nurse should assist the client into a left-lateral position for optimal results during a nonstress test.

B. Explain that nonreactivity might require immediate medication administration is incorrect. Nonreactivity can indicate fetal distress, but it does not necessarily require medication immediately. Further testing or evaluation would be needed first.

C. Remind the client to press the button when she feels fetal movement is correct. The purpose of the nonstress test is to monitor fetal heart rate acceleration in response to movement. The client is typically instructed to press a button when she feels fetal movement so the nurse can correlate it with fetal heart rate patterns.

D. Tell the client the test should take about 10 min is incorrect. The nonstress test typically takes 20–40 minutes, depending on fetal activity and the need for monitoring.

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Correct Answer is D

Explanation

A. Taking ferrous sulfate on an empty stomach can increase absorption but often causes nausea and gastrointestinal upset. Clients are usually advised to take it with a small amount of food if stomach upset occurs.

B. Drinking more milk does not prevent constipation and can actually decrease the absorption of iron due to calcium content. Adequate fluids and fiber are recommended instead to manage constipation.

C. Black stools are a common and expected side effect of ferrous sulfate due to iron content. Reporting them is not necessary unless accompanied by other concerning symptoms like bleeding or abdominal pain.

D. Mixing ferrous sulfate elixir with a full glass of water helps dilute the medication, reducing irritation to the gastrointestinal tract. It also ensures proper dosing and facilitates easier swallowing of the liquid medication.

A. Encourage the client to be assertive. B. Maintain a verbal no-harm contract with the client. C. Limit the client's social interactions. D. Assume responsibility for making the client's decisions.

Correct Answer is A

Explanation

A. Encourage the client to be assertive is correct. Encouraging assertiveness is important for a client with dependent personality disorder (DPD., as they often have difficulty making decisions or taking initiative. Teaching the client to express their needs, opinions, and desires is a key part of treatment and helps promote independence.

B. Maintain a verbal no-harm contract with the client is incorrect. While maintaining a no-harm contract may be appropriate for clients at risk for self-harm, this is not specific to dependent personality disorder. The main goal is to promote independence and healthy decision-making, not just ensuring safety.

C. Limit the client's social interactions is incorrect. In fact, encouraging healthy social interactions and gradual independence from others is often an important part of treatment for DPD. Limiting interactions could reinforce dependency and hinder progress.

D. Assume responsibility for making the client's decisions is incorrect. The nurse should encourage the client to make their own decisions and foster independence, rather than taking over their decisions, which could worsen the dependent behaviors.

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A nurse is assisting with the care of a client who is 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

Nursing Test Bank

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