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. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
Correct Answer is B
Explanation
A. Family history of cardiovascular disease: This is a non-modifiable risk factor. Family history can increase the likelihood of cardiovascular disease, but it cannot be changed.
B. Cholesterol 240 mg/dL: This is a modifiable risk factor. High cholesterol levels, particularly above 200 mg/dL, increase the risk of cardiovascular disease, and they can be managed through lifestyle changes, diet, and medication.
C. Sex: This is a non-modifiable risk factor. Men are generally at higher risk for cardiovascular disease at a younger age, while the risk increases for women after menopause.
D. Age 65: This is a non-modifiable risk factor. As people age, their risk for cardiovascular disease increases.
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