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 ["89.722"]
Explanation
To convert ounces to milliliters, we use the conversion factor: 1 oz = 29.5735 mL
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (0800 feedings)
1 oz = 1 * 29.5735 = 29.5735 mL (1100 feeding)
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (1300 feeding)
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (1600 feeding)
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (1830 feeding)
Total intake = 14.7868 + 29.5735 + 14.7868 + 14.7868 + 14.7868 = 89.722 mL
So, the nurse should record 89.722 mL of formula as the client's intake for the shift.
Correct Answer is D
Explanation
The correct answer is Choice D: Contraction lasting 85 seconds.
Choice A rationale: A contraction resting period of 35 seconds is normal and expected during labor. The resting period allows the uterine muscle to relax and replenish its oxygen supply, which is essential for fetal well-being. The resting period also gives the client a chance to rest and cope with the pain of labor. A normal resting period ranges from 30 to 90 seconds, depending on the stage and phase of labor¹².
Choice B rationale: A heart rate of 100/min for a 10-min period is within the normal range for an adult. The normal resting heart rate for an adult is 60 to 100 beats per minute (bpm)³. During labor, the heart rate may increase due to factors such as pain, anxiety, dehydration, fever, or infection. However, a heart rate of 100/min is not considered a sign of distress or complication, unless it is accompanied by other symptoms such as chest pain, shortness of breath, or palpitations⁴⁵.
Choice C rationale: Four contractions in a 10-min period is a normal frequency for labor contractions. The frequency of contractions refers to how often they occur, measured from the beginning of one contraction to the beginning of the next. The normal frequency of contractions varies depending on the stage and phase of labor, but generally ranges from two to five contractions in 10 minutes¹².
Choice D rationale: A contraction lasting 85 seconds is too long and should be reported to the provider. The duration of contractions refers to how long they last, measured from the beginning to the end of one contraction. The normal duration of contractions ranges from 30 to 70 seconds, depending on the stage and phase of labor¹². A contraction lasting longer than 90 seconds is considered a prolonged contraction, which can reduce the blood flow and oxygen supply to the placenta and the fetus, leading to fetal hypoxia and acidosis. Prolonged contractions can also cause uterine rupture, placental abruption, or maternal hemorrhage .
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