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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Increase the oxytocin infusion to 13 mu/min:

Anticipated: This action is anticipated. The nurse may consider adjusting the oxytocin infusion rate based on the progress of labor and the response to the current infusion rate.

Place client in a side-lying position:

Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

Initiate bolus of primary IV fluids:

Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.

Apply oxygen at 10 L/min via a venturi mask:

Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.

Perform sterile vaginal examination (SVE):

Nonessential: Based on the information provided, there is no indication for a sterile vaginal examination at this time. The cervical assessment was performed earlier at 0600, and frequent unnecessary SVEs can increase the risk of infection.

Assign a Bishop score:

Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed earlier at 0600, and the current focus is on monitoring the progress of labor with oxytocin.

A. Have the client void. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Notify the provider of the findings.

Correct Answer is B

Explanation

The correct answer is B. Position the client with one hip elevated.

A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.

B. Positioning the client with one hip elevated is the priority action.

The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.

C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.

D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 42 weeks of gestation Nurses Notes Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Correct Answer is B

Explanation

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