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: While smoking during pregnancy can have adverse effects on both the mother and the baby, it is not the most common risk factor for placental abruption.
Choice B rationale: Maternal battering, or experiencing domestic violence, can have serious consequences for the pregnant woman and her unborn baby, but it is not the most common risk factor for placental abruption.
Choice C rationale: Maternal cocaine use during pregnancy can lead to various complications, but it is not the most common risk factor for placental abruption.
Choice D rationale: Maternal hypertension is the most common risk factor for placental abruption. Placental abruption is a serious condition where the placenta separates from the uterine wall before delivery, leading to potential complications for both the mother and the baby. Hypertension can cause changes in blood vessels that increase the risk of placental abruption.
Correct Answer is A
Explanation
Choice A rationale: The umbilical cord contains three blood vessels: two arteries and one vein. The two arteries carry deoxygenated blood and waste products from the fetus back to the placenta, while the one vein carries oxygenated blood and nutrients from the placenta to the fetus.
Choice B rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins. It contains two arteries and one vein.
Choice C rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins and one artery. It contains two arteries and one vein.
Choice D Rationale: This option is incorrect because the umbilical cord in a newborn does not have only one artery and one vein. It contains two arteries and one vein.
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