A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?

Kleihauer-Betke test

Amnioinfusion

Administration of terbutaline

Contraction stress test

Answer and Explanation

The Correct Answer is D

A. Kleihauer-Betke test. This test is used to detect fetal-maternal hemorrhage by identifying fetal red blood cells in maternal circulation. It is not related to a nonreactive NST, which indicates the need for further fetal well-being assessment rather than checking for fetal-maternal bleeding.
B. Amnioinfusion. This procedure involves infusing fluid into the amniotic sac to relieve umbilical cord compression or dilute meconium-stained amniotic fluid. It is not an appropriate intervention for a nonreactive NST, as it does not assess fetal oxygenation or reactivity.
C. Administration of terbutaline. Terbutaline is a tocolytic used to relax the uterus and prevent preterm labor. It is not indicated for a nonreactive NST, as the concern in this scenario is fetal well-being rather than uterine activity.
D. Contraction stress test. A nonreactive NST means that the fetal heart rate does not demonstrate adequate accelerations, which can indicate potential fetal hypoxia. A contraction stress test is performed next to evaluate how the fetal heart rate responds to contractions, helping determine if the fetus can tolerate labor.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Nausea. Epinephrine is not primarily used to treat nausea. It is a sympathomimetic medication that works by stimulating alpha and beta receptors, mainly to counteract severe allergic reactions, including respiratory distress and hypotension. Nausea is not a primary indication for its use.
B. Hand tremors. Epinephrine can cause hand tremors as a side effect due to its stimulant effects on the nervous system. However, it is not used to treat tremors, and the presence of tremors after administration is a common physiological response rather than a therapeutic effect.
C. Hyperglycemia. Epinephrine can increase blood glucose levels by stimulating glycogenolysis and inhibiting insulin secretion. However, it is not used for treating hyperglycemia, and its effects on glucose metabolism are incidental rather than a primary therapeutic action.
D. Shortness of breath. Epinephrine is commonly used to treat anaphylaxis, which can cause airway swelling and bronchospasm leading to shortness of breath. By stimulating beta-2 receptors, epinephrine relaxes bronchial smooth muscles, improving airflow and reducing respiratory distress.

A. Baked chicken breast B. Sweet potato C. Orange juice D. Cantaloupe

Correct Answer is A

Explanation

A. Baked chicken breast is relatively low in potassium compared to other options. A 3-ounce serving of baked chicken typically contains around 250-300 mg of potassium, making it a suitable choice for someone needing to limit their potassium intake due to an electrolyte imbalance.
B. Sweet potato is high in potassium, with a medium-sized sweet potato containing about 440 mg or more. This makes sweet potatoes an unsuitable choice for clients who need to monitor their potassium levels, especially in the case of hyperkalemia.
C. Orange juice is also high in potassium, with a single cup containing approximately 450 mg. Therefore, orange juice is not recommended for clients with potassium restrictions, as excessive potassium can lead to serious health complications.
D. Cantaloupe is another food that is high in potassium. A typical serving of cantaloupe contains around 400 mg of potassium, making it inappropriate for individuals who need to maintain low potassium levels. Thus, it is essential to choose foods that are lower in potassium to help manage electrolyte imbalances effectively.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?

Nursing Test Bank

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