A nurse is caring for a client who is at 36 weeks of gestation and experiencing hypertension. Which of the following tests should the nurse use to monitor fetal well-being?

Maternal Hgb and Hct

Coombs test

Biophysical profile

Alpha fetoprotein

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Maternal hemoglobin and hematocrit levels are important indicators of the mother's health but are not direct indicators of fetal well-being.

Choice B rationale:

A Coombs test is performed on newborns to assess for hemolytic disease, not to monitor fetal well-being.

Choice C rationale:

A biophysical profile assesses multiple parameters of fetal well-being, including fetal heart rate, fetal movement, fetal breathing, amniotic fluid volume, and fetal tone.

Choice D rationale:

An alpha-fetoprotein test is a screening test for neural tube defects and chromosomal abnormalities but is not typically used to monitor fetal well-being in hypertensive pregnancies.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale:

Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.

Choice B rationale:

Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.

Choice C rationale:

Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.

Choice D rationale:

Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.

A. Establish a therapeutic relationship with the client. B. Instruct the client on stress management techniques. C. Have the client sign a no-suicide contract. D. Maintain constant observation of the client.

Correct Answer is D

Explanation

Choice A rationale:

Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.

Choice B rationale:

Instructing the client on stress management techniques is important, but safety comes first.

Choice C rationale:

Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.

Choice D rationale:

Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.

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A nurse is caring for a client who is at 36 weeks of gestation and experiencing hypertension. Which of the following tests should the nurse use to monitor fetal well-being?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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