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 D

Explanation

Choice A rationale: Ventricular septal defect (VSD) is a congenital heart defect and is not directly related to respiratory distress syndrome or respiratory acidosis.
Choice B rationale: Cesarean birth, while it can have other implications, is not a direct risk factor for respiratory distress syndrome or respiratory acidosis. The mode of delivery does not directly impact the newborn's respiratory function.
Choice C rationale: While being small for gestational age can be associated with certain health challenges, it is not a direct risk factor for respiratory distress syndrome or respiratory acidosis. The baby's size does not determine its respiratory status.
Choice D rationale: Maternal history of asthma is a risk factor that can predispose the newborn to respiratory difficulties, including respiratory distress syndrome (RDS) and respiratory acidosis. Infants born to mothers with asthma may have a higher likelihood of developing respiratory problems due to potential genetic factors and exposure to environmental triggers during pregnancy.

A. Reinforce teaching about ways to increase rest and sleep. B. Arrange for counseling to help the client cope with the stress of being a parent. C. Request a prescription for antidepressant medication. D. Use a postpartum depression screening tool with the client.

Correct Answer is D

Explanation

Choice A rationale: While adequate rest and sleep are essential postpartum, the client's symptoms of feeling down and sad may be indicative of postpartum depression and should be further evaluated.
Choice B rationale: Counseling may be helpful, but the priority is to first assess and screen for postpartum depression before making additional recommendations.
Choice C rationale: While antidepressant medications might be necessary for postpartum depression, the initial step should be to assess and screen for depression using the appropriate tool.
Choice D rationale: The client's statement and symptoms raise concerns about possible postpartum depression. Using a postpartum depression screening tool will help the nurse assess the severity of the client's symptoms and determine the appropriate course of action.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?

Correct Answer is D

Explanation

A nurse is caring for a client who is 2 weeks postpartum. The client tells the nurse, "I feel really down and sad lately. I have no energy and I feel like I'm going to cry." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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