A nurse is preparing to perform a nonstress test (NST) for a client who is at 36 weeks of gestation and reports decreased fetal movement.
Which of the following actions should the nurse take first?
Apply conduction gel to the client’s abdomen.
Instruct the client to press a button when she feels fetal movement.
Explain the purpose, procedure, and possible outcomes of the test to the client.
Activate a vibroacoustic stimulation device to wake up the fetus.
The Correct Answer is C
Explain the purpose, procedure, and possible outcomes of the test to the client. This is because the nurse should always obtain informed consent from the client before performing any procedure, and provide education and reassurance about the test.
Choice A is wrong because applying conduction gel to the client’s abdomen is not the first action the nurse should take. The nurse should first explain the test and obtain consent from the client before applying any equipment.
Choice B is wrong because instructing the client to press a button when she feels fetal movement is part of the nonstress test procedure, but not the first action. The nurse should first educate the client about the test and its purpose.
Choice D is wrong because activating a vibroacoustic stimulation device to wake up the fetus is not necessary for a nonstress test. This device may be used if the fetal heart rate is nonreactive, but only after explaining the test and obtaining consent from the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“This test will evaluate your baby’s well-being by monitoring his or her movements.”
A nonstress test (NST) is a simple, noninvasive way of checking on your baby’s health.The test records your baby’s movement, heartbeat, and reaction to movement.It is done after 26 to 28 weeks of pregnancyto check the health and oxygen supply of the fetus.It is safe, painless, and non-invasive, and can be performed in a doctor’s office or a hospital.It usually takes 40 to 60 minutes.
Choice A is wrong because this test will not measure the amount of amniotic fluid around your baby.That is done by another test called an amniotic fluid index (AFI).
Choice B is wrong because this test will not check if your baby has any chromosomal abnormalities.That is done by other tests such as amniocentesis or chorionic villus sampling (CVS).
Choice C is wrong because this test will not assess how your baby’s heart rate responds to contractions.That is done by another test called a contraction stress test (CST).
Correct Answer is C
Explanation
The nurse should instruct the client to brush her nipple with her palm for 2 minutes.
This will stimulate the release of oxytocin and cause uterine contractions.The fetal heart rate (FHR) will be monitored for any signs of fetal distress, such as decelerations.
Choice A is wrong because fasting is not required for a CST.Fasting may be necessary for other tests that involve anesthesia or sedation.
Choice B is wrong because drinking orange juice will not induce contractions.Orange juice may be given to increase fetal activity before a nonstress test (NST), which measures the FHR response to fetal movement.
Choice D is wrong because lying on the back can compress the inferior vena cava and reduce blood flow to the uterus and the fetus.The client should lie on her side during the test to prevent supine hypotension syndrome.
Normal ranges for FHR are 110 to 160 beats per minute, with moderate variability and no decelerations.Normal ranges for uterine contractions are less than five in a 10-minute period, lasting less than 90 seconds each.
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