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 B
Explanation
A. "Replace the ear molds once per year" is incorrect. Ear molds should be checked regularly for wear and tear, but they should be replaced as needed rather than on a fixed schedule like once a year.
B. "Clean the hearing aid with a soft cloth" is correct. Cleaning the hearing aid with a soft cloth helps to maintain the device, removing dirt and debris without damaging the electronics. It is important to avoid using harsh chemicals or abrasive materials that could harm the hearing aid.
C. "Disinfect the hearing aid with isopropyl alcohol" is incorrect. Isopropyl alcohol is too harsh for cleaning hearing aids and can damage the components. The hearing aid should only be cleaned with appropriate methods, such as a dry cloth or cleaning brush.
D. "Change the battery once per month" is incorrect. The battery should be checked more frequently, as it typically needs to be replaced more often (e.g., every 7-10 days), depending on usage. Changing it once a month may not ensure optimal performance.
Correct Answer is C
Explanation
A. Decreased body temperature is incorrect. A thyroid storm is characterized by a hypermetabolic state, so a decreased body temperature would be inconsistent with the condition. In fact, patients with thyroid storm typically have increased body temperature (fever).
B. Increased incisional drainage is incorrect. While increased drainage could indicate a wound infection or other surgical complications, it is not a primary indicator of thyroid storm, which involves a hyperactive thyroid response.
C. Hypertension is correct. Thyroid storm is a severe, acute exacerbation of hyperthyroidism, and it is associated with hypertension, tachycardia, fever, and other symptoms of sympathetic nervous system overactivity.
D. Bradycardia is incorrect. Bradycardia would be expected in conditions like hypothyroidism, not thyroid storm. Thyroid storm typically presents with tachycardia, which is a hallmark sign.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.