A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

Immediately report the situation to the client's provider and prepare the client for induction of labor.

Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.

Turn the client onto her left side.

Offer the client a snack of orange juice and crackers

Answer and Explanation

The Correct Answer is D

A. Immediately report the situation to the client's provider and prepare the client for induction of labor. This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.

B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.

C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.

D. Offer the client a snack of orange juice and crackers. This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.

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Correct Answer is D

Explanation

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Routinely inserting an indwelling urinary catheter is not necessary for maintaining an empty bladder during labor. While it is important to ensure the client has a voiding schedule, the use of an indwelling catheter should be reserved for specific medical indications, such as when the client is unable to void or has received an epidural. Indwelling catheters can increase the risk of catheter-associated urinary tract infections (CAUTIs) and should be used judiciously.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Keeping all four side rails up and maintaining strict bedrest is not appropriate during active labor. This practice can limit the client’s movement, which is essential for comfort and progress during labor. Movement and changing positions can help labor progress and reduce pain. Strict bedrest is generally reserved for specific medical conditions, such as preterm labor or other complications.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus. However, hourly monitoring may not be sufficient. Guidelines recommend more frequent monitoring, typically every 15-30 minutes during the active phase of labor and every 5-15 minutes during the second stage. Continuous electronic fetal monitoring may be used for high-risk pregnancies or if there are signs of fetal distress.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Checking the cervix to determine how close the time of delivery may be prior to analgesic administration is important. This practice helps ensure that analgesics are administered at an appropriate time, avoiding potential complications such as delayed delivery or inadequate pain relief. Cervical checks provide valuable information about the progress of labor and help guide clinical decisions regarding pain management and delivery planning.

A. "This will determine if there is more than one fetus." B. "It assists in identifying the location of the placenta and fetus." C. "This is a screening tool for spina bifida." D. "It is useful for estimating fetal age."

Correct Answer is B

Explanation

Choice A: An ultrasound can indeed determine the number of fetuses if a client is carrying multiples, but this is not the primary reason for performing an ultrasound before amniocentesis.

Choice B: An ultrasound is typically done before an amniocentesis to visualize the location of the placenta and fetus. This information is important to ensure that the amniocentesis needle is safely inserted away from the placenta and the fetus.

Choice C: The primary purpose of an amniocentesis is to obtain a sample of amniotic fluid to screen for genetic conditions, not specifically for spina bifida.

Choice D: Fetal age can be estimated through an ultrasound, but this is not the primary reason for performing an ultrasound before an amniocentesis. The main goal of the procedure is to obtain a sample of amniotic fluid for genetic testing.

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A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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