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.
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Related Questions
Correct Answer is B
Explanation
A. To stay with the client's body for 8 hr following their death: While it is common for family members to stay with the deceased, the duration of time can vary and is not specifically aligned with Hindu customs.
B. To cremate the client's body: In Hinduism, cremation is the most common practice following death. The family is likely to request this as it aligns with religious beliefs and traditions.
C. To prohibit medical personnel from touching the client's body: In Hinduism, there is no blanket prohibition against medical personnel touching the body. However, some families may have specific requests for the handling of the body, but this is not universally expected.
D. To bury the client's body within 24 hr of their death: Hindus typically prefer cremation rather than burial. While burial is practiced in certain Hindu traditions, cremation is far more common, and the request for burial within 24 hours may not apply.
Correct Answer is A
Explanation
A. Right upper quadrant is correct. A colostomy placed in the ascending colon is typically located in the right upper quadrant of the abdomen. The ascending colon runs along the right side of the abdomen, so the stoma will be located in that region.
B. Left lower quadrant is incorrect. The left lower quadrant is typically where the descending colon or sigmoid colon are located, so a colostomy placed here would be for those regions, not the ascending colon.
C. Left upper quadrant is incorrect. The left upper quadrant contains parts of the stomach, spleen, and pancreas, but not the ascending colon. A colostomy in the ascending colon would not be located here.
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