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 B
Explanation
Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.
Correct Answer is C
Explanation
Choice A rationale:
A gynaecoid pelvis is considered the most favorable pelvic shape for childbirth and is not a contributing cause of difficult, prolonged labor.
Choice B rationale:
A longitudinal fetal lie (baby's spine aligned with the mother's spine) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
Choice C rationale:
A persistent occiput posterior position (baby's head facing the mother's abdomen instead of her back) can be a contributing cause of difficult, prolonged labor and may lead to a severe backache for the mother.
Choice D rationale:
Fetal attitude in general flexion (baby's head flexed forward, chin to chest) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
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