A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

The client will demonstrate proper bathing of the infant.

The client will verbalize appropriate car seat safety.

The client will identify individual family member roles.

The client will have adequate nutritional intake.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

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Correct Answer is A

Explanation

Choice A rationale:
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice B rationale:
Applying pressure on the client’s suprapubic area is not part of the McRoberts maneuver. However, when coupled with suprapubic pressure, the effectiveness of the McRoberts maneuver increases to 90%1.
Choice C rationale:
Moving the client onto their hands and knees is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Choice D rationale:
Applying pressure to the client’s fundus is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.

A. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period. B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period. C. Three fetal movements perceived by the client in a 20-min testing period. D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.

Correct Answer is C

Explanation

The correct answer is Choice C.

A nonstress test (NST) is a safe and noninvasive test used to check a baby’s health before birth. NSTs are a form of electronic fetal monitoring. In addition, nonstress tests are normally performed 26 to 30 weeks into pregnancy. This is because, in healthy babies, fetal heart rate increases with movement.

Nonstress test results are given as one of the following:

Reactive or Reassuring. This means the baby’s heart rate increased two or more times during the testing period.

Nonreactive. This means the baby’s heartbeat didn’t change when the baby moves, or the baby wasn’t moving much. A nonreactive result doesn’t always mean your baby has a health problem.

Based on this information, the correct answer to your question is c. Three fetal movements perceived by the client in a 20-min testing period indicate a nonreactive result, which should prompt further diagnostic testing. The other options are normal or reassuring findings for a nonstress test.

Choice A rationale: An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding and indicates a reactive nonstress test. A reactive nonstress test means that the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds in response to fetal movement, at least twice in a 20-min period. This shows that the fetus is well-oxygenated and has an intact central nervous system. Therefore, this finding does not indicate the need for further diagnostic testing.

Choice B rationale: No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is also a normal finding and indicates a negative contraction stress test. A negative contraction stress test means that there are no late decelerations in the fetal heart rate with at least three uterine contractions of 40 to 60 seconds in duration within a 10-min period. Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia, and they occur when the fetal heart rate drops below the baseline after the peak of the contraction. Therefore, this finding does not indicate the need for further diagnostic testing.

Choice C rationale: Three fetal movements perceived by the client in a 20-min testing period is an abnormal finding and indicates a nonreactive nonstress test. A nonreactive nonstress test means that the fetal heart rate does not increase by at least 15 beats per minute for at least 15 seconds in response to fetal movement, even after 40 min of testing. This may suggest that the fetus is asleep, sedated, or compromised. Therefore, this finding indicates the need for further diagnostic testing, such as a biophysical profile or a contraction stress test, to assess the fetal well-being.

Choice D rationale: Irregular contractions of 10 to 20 seconds in duration that are not felt by the client are not relevant to the nonstress test, as they do not affect the fetal heart rate or the uteroplacental perfusion. These contractions may be Braxton Hicks contractions, which are painless and irregular contractions that occur throughout pregnancy. They do not indicate labor or fetal distress. Therefore, this finding does not indicate the need for further diagnostic testing.

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A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Correct Answer is C

Explanation

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