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.

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Correct Answer is B

Explanation

A. Place area rugs on slick floor surfaces. Area rugs can increase the risk of falls, especially on slippery floors. They can easily shift or curl at the edges, creating tripping hazards. If rugs are necessary, they should be secured with non-slip backing or removed entirely for safety.
B. Move the client's bed to the main floor of the house. Reducing the need to navigate stairs decreases fall risk, especially for clients with mobility issues. Keeping essential living spaces, such as the bedroom and bathroom, on one level minimizes hazards and promotes safer movement within the home.
C. Keep lighting in the home dim. Adequate lighting is essential for fall prevention, particularly in hallways, staircases, and bathrooms. Dim lighting can make it difficult to see obstacles, increasing the likelihood of tripping. Bright, well-distributed lighting helps ensure visibility and safety.
D. Place the bedside table 2 feet away from the bed. The bedside table should be within easy reach to prevent overextending or getting out of bed unnecessarily. Keeping essential items, such as water, medications, or a phone, close to the bed minimizes the need for unnecessary movement that could lead to falls.

A. Anterior fontanel closed B. Moves objects to mouth C. Rolls from back to abdomen D. Posterior fontanel closed

Correct Answer is A

Explanation

A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.

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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?

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