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.
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Correct Answer is D
Explanation
Choice A rationale:
Increasing the rate of the maintenance IV infusion may be a rational action in some situations, but it is not the first priority when dealing with a fetal heart rate deceleration. The priority is to address the deceleration and potential fetal distress promptly.
Choice B rationale:
Administering oxygen using a nonrebreather mask might be beneficial for the client, but it is not the primary action to take when dealing with fetal heart rate deceleration. The priority is to address the deceleration and ensure fetal well-being.
Choice C rationale:
Elevating the client's legs is unlikely to have a significant impact on fetal heart rate deceleration. This action is more relevant in cases of maternal hypotension or when trying to improve venous return to the heart. It is not the first-line intervention for fetal heart rate decelerations.
Choice D rationale:
Placing the client in the lateral (side-lying) position is the correct action to take first. This position can help relieve pressure on the vena cava, improve blood flow, and increase oxygen supply to the fetus. By changing the client's position, the nurse can potentially resolve the fetal heart rate deceleration and improve fetal well-being.
Correct Answer is C
Explanation
Choice A (7) rationale: The nurse should not select 7 as the Apgar score because the newborn exhibited several positive signs at 5 minutes after birth, such as a heart rate of 130/min, a lusty cry with tactile stimulation, and flexed extremities, indicating good muscle tone and reflexes.
Choice B (8) rationale: Choice B can be eliminated as the correct answer because the newborn displayed more than just moderate signs of normal adaptation. With a heart rate of 130/min, a lusty cry with tactile stimulation, and flexed extremities, as well as acrocyanosis and a grimace when suctioned, the newborn shows excellent adaptation to extrauterine life.
Choice C (9) rationale: The nurse should select Choice C as the correct answer. At 5 minutes after birth, the newborn's Apgar score would be 9 because it exhibited good overall adaptation with a heart rate of 130/min, a lusty cry with tactile stimulation, flexed extremities, and some acrocyanosis and grimace when suctioned.
Choice D (10) rationale: Choice D (10) should be excluded as the correct answer since the newborn had acrocyanosis and a grimace when suctioned, which indicates some minor difficulty in adapting to the new environment.
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