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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:
Maternal serum alpha-fetoprotein (MSAFP) determination is not used to screen for ABO incompatibility. It is specifically used to screen for certain fetal abnormalities.
Choice B rationale:
MSAFP determination is not used to screen for gestational diabetes. It is primarily used for detecting certain fetal abnormalities.
Choice C rationale:
The MSAFP test is a prenatal screening test that measures the level of alpha-fetoprotein in the mother's blood. Abnormal levels of alpha-fetoprotein may indicate a neural tube defect, such as spina bifida, or other chromosomal abnormalities.
Choice D rationale:
MSAFP determination is not used to screen for fetal maturity. It is used to assess the risk of certain fetal abnormalities.

A. Supine hypotension B. Constipation C. Urinary frequency D. Heartburn

Correct Answer is B

Explanation

Choice A rationale: Supine hypotension is a condition that can occur later in pregnancy when the pregnant woman lies flat on her back, leading to decreased blood flow to the heart and brain.
This discomfort is more common in the second and third trimesters, not during the first trimester.
Choice B rationale: Constipation is a common discomfort experienced by pregnant women, especially during the first trimester. It is often caused by hormonal changes and pressure on the intestines as the uterus grows. Increasing fiber intake, drinking plenty of fluids, and regular physical activity can help alleviate constipation.
Choice C rationale: Urinary frequency is a common discomfort during pregnancy, but it is not specific to the first trimester. It can occur throughout pregnancy due to increased pressure on the bladder as the uterus grows.
Choice D rationale: Heartburn is a common discomfort during pregnancy, but it is more prevalent in the second and third trimesters. It is caused by hormonal changes and pressure on the stomach from the growing uterus.

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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?

Nursing Test Bank

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