A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Tell the client to follow up with a dermatologist

Explain to the client this is an expected occurrence.

instruct the client to increase her intake of vitamin D

Inform the client she might have an allergy to her skin care products

Answer and Explanation

The Correct Answer is B

The correct answer is B. Explain to the client this is an expected occurrence.

A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.

B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.

C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.

D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.

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Correct Answer is B

Explanation

Choice A Reason:

Active is incorrect. The active phase of labor typically begins when the cervix is around 4 to 6 centimeters dilated. Given that the client's cervix is already dilated to 9 cm, she has progressed beyond the active phase.

Choice B Reason:

Transition is correct. The transition phase is the final part of the first stage of labor and occurs when the cervix is dilated from 8 to 10 centimeters. In this phase, contractions are typically strong, occurring every 2 to 3 minutes, and lasting 80 to 90 seconds. The sensation of increasing rectal pressure is common during the transition phase as the baby's head descends further into the birth canal. The advanced cervical dilation to 9 cm also indicates that the client is in the transition phase, preparing for the second stage of labor.

Choice C Reason:

Latent is incorrect. The latent phase is the early part of the first stage of labor, characterized by cervical dilation from 0 to 3 or 4 centimeters. The client's cervix is already dilated to 9 cm, indicating that she has progressed well beyond the latent phase.

Choice D Reason:

Descent is incorrect. The descent phase is generally associated with the second stage of labor, during which the baby moves through the birth canal. The information provided primarily relates to the first stage of labor, specifically the transition phase, as indicated by the cervical dilation of 9 cm.

A. Maintain the client NPO throughout the procedure. B. Place the client in a supine position, C. Instruct the client to massage the abdomen to stimulate fetal movement D. Instruct the client to press the provided button each time fetal movement is detected

Correct Answer is D

Explanation

The correct answer is D.

A. Maintain the client NPO throughout the procedure: It is not necessary to maintain the client NPO (nothing by mouth) for a nonstress test. The test primarily involves monitoring fetal heart rate in response to the baby's movements and does not require fasting.

B. Place the client in a supine position: Placing the client in a left lateral position is often preferred for NST to optimize uterine blood flow and fetal oxygenation. The supine position can compromise blood flow to the uterus and is generally avoided, especially in later pregnancy.

C. Instruct the client to massage the abdomen to stimulate fetal movement: While the goal of the NST is to monitor fetal movements, instructing the client to actively stimulate fetal movement through abdominal massage is not a standard part of the procedure. Fetal movements should occur naturally.

D. Instruct the client to press the provided button each time fetal movement is detected: This is the correct action. During a nonstress test, the client is typically provided with a button to press whenever she feels fetal movement. This helps correlate fetal movements with changes in the fetal heart rate on the monitor, providing valuable information about the baby's well-being.

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A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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