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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Placing a rolled towel beneath one of the client's hips may be helpful to tilt the client and alleviate pressure, but it is not the first action.
Choice B Reason:
Applying internal upward pressure to the presenting part using two gloved fingers is appropriate. This maneuver, known as "manual elevation of the presenting part," helps lift the presenting part off the prolapsed cord, preventing compression and maintaining blood flow to the fetus. This action should be performed while waiting for additional assistance and interventions.
Choice C Reason:
Administering oxygen is important for the well-being of the fetus, but the immediate focus is on relieving pressure on the umbilical cord.
Choice D Reason:
Increasing the infusion rate may be necessary later, but the immediate priority is to address the prolapsed cord and ensure fetal oxygenation.
4.A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse Include?
A. Place the shoulder harness in the slots above the newborn's shoulders.
B. Place the retainer clip at the level of the newborn's armpits.
C. Place the newborn at a 60° angle in the car seat.
D. Place the newborn in a blanket before securing them in the car seat.
Explanation
The correct answer is choice B
Choice A Reason:
Placing the shoulder harness in the slots above the newborn's shoulders is incorrect. The harness should be threaded through the slots at or below the baby's shoulders to provide proper protection.
Choice B Reason:
Placing the retainer clip at the level of the newborn's armpits is correct. This is a critical safety measure to ensure that the harness straps are positioned correctly on the newborn. Placing the retainer clip at the level of the armpits helps secure the harness straps over the baby's shoulders and prevents them from slipping off.
Choice C Reason:
Placing the newborn at a 60° angle in the car seat is not a standard recommendation. The car seat should be installed according to the manufacturer's instructions, and the baby should be placed in a semi-reclined position, typically at a 45° angle, to ensure proper support for the newborn's head and airway.
Choice D Reason:
Placing the newborn in a blanket before securing them in the car seat is not recommended. Extra padding, including bulky clothing or blankets, should not be placed under the harness straps as it can compromise the effectiveness of the restraint system. The baby should be dressed in thin layers, and if additional warmth is needed, a blanket can be placed over the baby after securing them in the car seat.
Correct Answer is B
Explanation
A. Shoulder presentation is not typically described using the terms RSA. Shoulder presentation would be noted differently, and it is uncommon.
B. Breech presentation involves the presentation of the fetus with the buttocks or feet first. RSA indicates the specific position of the sacrum in relation to the mother's right side.
C. Vertex presentation refers to the head-first position, and it is not described using the terms RSA.
D. Mentum presentation is not a standard term used to describe fetal presentation. Mentum typically refers to the chin, and fetal presentations are commonly described in terms of the presenting part (e.g., vertex, breech).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today