A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

Perform vibroacoustic stimulation.

Place the client in the Trendelenburg position.

Conduct a vaginal exam.

Collect a specimen for an indirect Coombs' test.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.

Choice B rationale:

Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.

Choice C rationale:

Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.

Choice D rationale:

Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice Arationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.

Choice Brationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.

Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.

Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.

A. Temperature 37.4°C (99.3°F). B. Uterine tenderness. C. WBC Count 9,000/mm. D. Scant lochia.

Correct Answer is B

Explanation

Choice A rationale:

A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.

Choice B rationale:

Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.

Choice C rationale:

A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.

Choice D rationale:

Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.

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A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client?

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