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: Stopping breastfeeding is not an appropriate response to breast engorgement. Continuing to breastfeed frequently and effectively can help relieve the engorgement and ensure adequate milk supply.
Choice B rationale: While frequent breastfeeding is beneficial for both the baby and mother, this statement does not directly address breast engorgement.
Choice C rationale: Wearing a supportive bra during the daytime can actually help reduce breast engorgement and discomfort by providing gentle pressure and support to the breasts.
Choice D rationale: Breast engorgement is a common issue for breastfeeding mothers, especially during the early days after delivery. Applying cold compresses to the breasts before each feeding can help reduce swelling and discomfort associated with engorgement, making it easier for the baby to latch onto the breast.
Correct Answer is C
Explanation
Choice A rationale: Kernicterus is a severe form of jaundice that can result from untreated hyperbilirubinemia in a newborn. The indirect Coombs test does not assess the risk of kernicterus specifically.
Choice B rationale: The indirect Coombs test detects Rh-negative antibodies in the mother's blood, not Rh-positive antibodies.
Choice C rationale: The indirect Coombs test, also known as the indirect antiglobulin test (IAT), is performed on a pregnant woman to detect the presence of Rh-negative antibodies in her blood. If the mother is Rh-negative and has been sensitized to Rh-positive blood, these antibodies can cross the placenta and attack the red blood cells of an Rh-positive fetus, potentially causing hemolytic disease of the newborn (HDN) or erythroblastosis fetalis.
Choice D rationale: The direct Coombs test (direct antiglobulin test) is used to detect the presence of maternal antibodies that have already been attached to the newborn's red blood cells. The indirect Coombs test is used to identify the presence of these antibodies in the mother's blood before they have attached to the newborn's red blood cells.
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