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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. The AP points the probe posteriorly is incorrect. When using a tympanic thermometer for adults or children older than 3 years, the probe should be directed posteriorly and slightly upwards to align with the ear canal. The posterior direction is correct for adults, but this phrasing is not precise enough for the intended technique.

B. The AP pulls the pinna up and back is correct. When taking the temperature of a client older than 3 years using a tympanic thermometer, the pinna (ear) should be pulled up and back to straighten the ear canal and ensure accurate measurement. This action indicates the AP understands proper technique.

C. The AP positions the client facing her is incorrect. The client’s position does not directly affect the ability to take a tympanic temperature. The focus should be on positioning the ear and probe, not on facing the nurse.

D. The AP inserts the probe with a straight, forward motion is incorrect. The correct motion is straight into the ear canal, not forward, and it is more precise when the probe is inserted gently without forcing it.

A. Hold the irrigation solution bottle 5 cm (2 in) above the sterile container. B. Open the outer wrapper of the sterile package toward her body. C. Place the irrigation solution bottle cap on the sterile field. D. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

Correct Answer is D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is B

Explanation

A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?