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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “Discontinue the medication. I will ask your provider for another antibiotic.”: This is correct. Ciprofloxacin and other fluoroquinolones are associated with a risk of tendonitis and tendon rupture, particularly in the Achilles tendon. The pain in the calf muscle could indicate this side effect. The nurse should recommend discontinuing the medication and notifying the provider for further evaluation.
B. “That reaction means your dose is too high. Cut the pill in half.”: This is incorrect. The pain in the calf muscle is likely related to a known side effect of ciprofloxacin, rather than the dose being too high. Adjusting the dose is not the appropriate solution.
C. “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.”: This is incorrect. Calf pain may be indicative of a serious side effect, such as tendonitis or tendon rupture, and the medication should be discontinued until the provider evaluates the client.
D. “This is an allergic reaction. Take the medication with an antihistamine.”: This is incorrect. The pain in the calf muscle is more likely due to tendon-related side effects, not an allergic reaction. Ciprofloxacin-related tendon pain requires immediate attention, and antihistamines would not address the underlying issue.
Correct Answer is D
Explanation
A. Leaving noninvasive equipment on the client’s body is not appropriate during postmortem care. Tubing and devices should be removed unless an autopsy is required.
B. Dentures should generally be left in place to maintain the natural shape of the face and promote a more normal appearance for family viewing.
C. Turning the lights up is unnecessary and may create a harsh environment. A calm, respectful setting with normal or dim lighting is preferred during postmortem care.
D. Closing the client’s eyes before the family views the body helps provide a peaceful and dignified appearance and is an important part of postmortem care.
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