A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

Quickening

Ballottement

Chloasma

Lightening

Answer and Explanation

The Correct Answer is A

A)   Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B)   Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C)   Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D)   Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.

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Correct Answer is B

Explanation

A) The largest fetal diameter has passed through the pelvic outlet: This is an incorrect

interpretation of station 0. Station 0 means that the presenting part is at the level of the ischial spines, not fully descended through the pelvic outlet.

B) The lowermost portion of the presenting part is at the level of the ischial spines: This is the correct interpretation of station 0. Station 0 is the landmark at which the presenting part is at the level of the ischial spines in the maternal pelvis.
C) The posterior fontanel is palpable: The position of the fontanelle is not related to the station of the presenting part.
D) The fetal head is in the left occiput posterior position: The position of the fetal head is not indicated by the station measurement.

A. Increase the oxytocin infusion to 13 mu/min. B. Initiate a bolus of primary IV fluids. C. Place the client in a sidelying position. D. Apply oxygen at 10 L/min via a venturi mask. E. Perform a sterile vaginal examination (SVE).

Correct Answer is ["B","C","D"]

Explanation

The correct answer is B, C, and D.

Choice A: Increase the oxytocin infusion to 13 mu/min

Increasing the oxytocin infusion is not indicated in this scenario. Oxytocin is used to induce or augment labor, but if the fetal heart rate tracing is abnormal (Category 3), increasing oxytocin could exacerbate fetal distress. The priority is to stabilize the fetal condition before considering increasing oxytocin.

Choice B: Initiate a bolus of primary IV fluids

Initiating a bolus of primary IV fluids is appropriate. This action helps improve placental perfusion and maternal hydration, which can be beneficial in response to abnormal fetal heart rate tracings. Adequate hydration can enhance uteroplacental blood flow and improve fetal oxygenation.

Choice C: Place the client in a sidelying position

Placing the client in a sidelying position is recommended. This position can improve uteroplacental perfusion and fetal oxygenation, especially if there are signs of fetal distress. It helps to alleviate pressure on the inferior vena cava, enhancing blood flow to the placenta.

Choice D: Apply oxygen at 10 L/min via a venturi mask

Applying oxygen at 10 L/min via a venturi mask is indicated for improving fetal oxygenation in cases of abnormal fetal heart rate patterns. This intervention can help increase the oxygen available to the fetus, which is crucial in managing fetal distress.

Choice E: Perform a sterile vaginal examination (SVE)

Performing a sterile vaginal examination (SVE) is not indicated based on the provided assessment findings. While SVE is useful for assessing cervical dilation and labor progression, it is not a priority in this situation where the main concern is fetal well-being. Unnecessary SVEs can increase the risk of infection.

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A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

Nursing Test Bank

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