A nurse is reinforcing teaching with a client who is at 30 weeks of gestation and scheduled for a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?
"I need to schedule the test when the baby is usually active.".
"The baby's heart rate will be monitored during the test.".
"I will have to lie on my back during the test.".
"I will be able to go to the bathroom during the test as necessary.".
The Correct Answer is C
Choice A rationale:
The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.
Choice B rationale:
The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.
Choice C rationale:
This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.
Choice D rationale:
The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should schedule a 3-hour oral glucose tolerance test (OGTT) for the client because the blood glucose levels taken 1 hour following a meal are higher than the expected range for gestational diabetes. This test will help to diagnose and assess the client's glucose tolerance and determine if there is gestational diabetes or any other potential glucose regulation issues.
Choice B rationale:
Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.
Choice C rationale:
Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.
Choice D rationale:
Reinforcing instruction about insulin administration is not warranted at this point since there is no information indicating that the client is currently on insulin therapy. Additionally, using insulin as the first step in the management of gestational diabetes is not common practice. Lifestyle modifications, dietary changes, and other measures are usually attempted first.
Correct Answer is C
Explanation
Choice A rationale:
A fetal heart rate of 100/min for a 10-minute period is considered within the normal range. The normal fetal heart rate can range from 110 to 160 beats per minute, and a rate of 100 is not concerning.
Choice B rationale:
The resting period of a contraction refers to the time between contractions when the uterus is relaxed. A resting period of 35 seconds is also considered normal. In labor, the resting period between contractions allows the placenta to receive oxygen and nutrients, and 35 seconds is a rationaleable duration.
Choice C rationale:
A contraction lasting 85 seconds is abnormal and should be reported to the provider. Normally, contractions last around 60-90 seconds, but an 85-second contraction may indicate uterine hyperactivity or other issues that could potentially affect the well-being of both the mother and the baby.
Choice D rationale:
Having four contractions in a 10-minute period is considered normal during labor. In fact, an average pattern includes 3-5 contractions within a 10-minute window, so this finding is not a cause for concern.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.