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 A
Explanation
Choice A rationale:
A newborn can lose up to 10% of their birth weight in the first few days after birth, which is considered normal. By 7-14 days of age, the baby should have regained their birth weight if breastfeeding effectively.
Choice B rationale:
Gaining 0.25 oz (7 grams) per day after the fourth day of life is not a standard guideline for assessing effective breastfeeding.
Choice C rationale:
Expecting the baby to have less than 5 wet diapers per day after the fourth day of life may indicate dehydration or inadequate breastfeeding, which is not a sign of effective breastfeeding.
Choice D rationale:
Expecting the baby to feed constantly during the first week of life is not necessarily an indicator of effective breastfeeding. While frequent feeding is normal in the early days, the baby should be able to effectively feed and show signs of satiety after nursing.
Correct Answer is B
Explanation
A. SGA newborns often have increased circulating RBCs (polycythemia) due to chronic hypoxia in utero, not decreased RBCs.
B. Blood glucose instability (hypoglycemia) is common in SGA newborns due to decreased glycogen stores and increased metabolic demands.
C. Retinopathy of prematurity is more commonly associated with preterm infants and prolonged oxygen therapy rather than SGA status.
D. SGA newborns typically have a scaphoid (sunken) rather than a well-rounded abdomen due to decreased subcutaneous fat stores.
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