A nurse is caring for a client who is pregnant and undergoing a nonstress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take?
Turn the client onto her left side.
Encourage the client to walk around and then resume monitoring.
Apply vibroacoustic stimulation to the woman's abdomen.
Report the findings to the provider and prepare the client for induction of labor.
The Correct Answer is C
Choice A rationale:
Turning the client onto her left side is a common measure to improve fetal oxygenation and is often used during labor. However, in this scenario, the nurse needs to address the absence of fetal movement during the nonstress test.
Choice B rationale:
Encouraging the client to walk around and then resume monitoring is not appropriate when there is a concern about the absence of fetal movement during the nonstress test.
Choice C rationale:
Vibroacoustic stimulation involves using sound stimulation to elicit fetal movement. If there has been no fetal movement during the nonstress test, this intervention can be used to assess fetal well-being and provoke a response from the fetus.
Choice D rationale:
Preparing the client for induction of labor is not indicated based solely on the absence of fetal movement during a nonstress test. Further assessment and interventions are needed before considering induction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: This response dismisses the client's concerns and is not helpful or informative.
Choice B rationale: While some situations may warrant a repeat cesarean section, this response is not appropriate without knowing the client's specific medical history and the reason for the previous cesarean birth.
Choice C rationale: While there are indeed various factors that impact the possibility of VBAC, the nurse can still provide some general information and considerations to the client, especially regarding the type of uterine incision.
Choice D rationale: This option provides appropriate information to the client regarding VBAC. The type of uterine incision from the previous cesarean birth is a crucial factor in determining whether VBAC is safe and feasible. Clients with a low transverse uterine incision generally have a higher likelihood of being candidates for VBAC.
Correct Answer is D
Explanation
Choice A rationale: This response is not supportive and may cause the client to feel pressured or inadequate. It is essential to be empathetic and understanding of the client's feelings and needs.
Choice B rationale: The nurse should encourage the client to begin breastfeeding and offer support if needed. This response does not promote the client's active involvement in caring for her newborn.
Choice C rationale: While breastfeeding is a natural process, it can be challenging for some women, especially in the early days. This response may minimize the client's concerns and emotions.
Choice D rationale: The nurse should be supportive and reassuring to the postpartum client. The client may be feeling overwhelmed or uncertain about breastfeeding, so offering assistance and staying with the client to help with the first feeding is an appropriate and compassionate response.
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