A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Maintain the client NPO throughout the procedure.

Place the client in a supine position,

Instruct the client to massage the abdomen to stimulate fetal movement

Instruct the client to press the provided button each time fetal movement is detected

Answer and Explanation

The Correct Answer is D

The correct answer is D.

A. Maintain the client NPO throughout the procedure: It is not necessary to maintain the client NPO (nothing by mouth) for a nonstress test. The test primarily involves monitoring fetal heart rate in response to the baby's movements and does not require fasting.

B. Place the client in a supine position: Placing the client in a left lateral position is often preferred for NST to optimize uterine blood flow and fetal oxygenation. The supine position can compromise blood flow to the uterus and is generally avoided, especially in later pregnancy.

C. Instruct the client to massage the abdomen to stimulate fetal movement: While the goal of the NST is to monitor fetal movements, instructing the client to actively stimulate fetal movement through abdominal massage is not a standard part of the procedure. Fetal movements should occur naturally.

D. Instruct the client to press the provided button each time fetal movement is detected: This is the correct action. During a nonstress test, the client is typically provided with a button to press whenever she feels fetal movement. This helps correlate fetal movements with changes in the fetal heart rate on the monitor, providing valuable information about the baby's well-being.

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Correct Answer is A

Explanation

The correct answer is A.

A. Shortness of breath: Shortness of breath can be a serious side effect of combined oral contraceptives (COCs) and may indicate a potential risk of a blood clot or other cardiovascular issues. It is crucial for the client to seek medical attention promptly if experiencing shortness of breath.

B. Breakthrough bleeding: Breakthrough bleeding is a common side effect of COCs, especially during the first few months of use. While it can be bothersome, it is generally not considered a serious adverse effect. However, the healthcare provider may need to adjust the dosage or type of contraceptive if breakthrough bleeding persists.

C. Vomiting: Vomiting can decrease the absorption of COCs, and if vomiting occurs within a few hours after taking the pill, a backup form of contraception may be needed. However, it is not necessarily an adverse effect that requires immediate notification unless it leads to an inability to take the medication consistently.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives and is generally not considered a serious adverse effect. Clients are often advised to monitor for changes in breast tenderness, but it does not require immediate notification.

A. Massage the client's fundus. B. Insert an indwelling urinary catheter. C. Administer oxygen at 10 L/min D. Elevate the client's right hip

Correct Answer is A

Explanation

A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.

B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.

C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.

D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.

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A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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