A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse make?
"You will be lying flat on your back for the duration of the test.”
"At some point during the test, you will need to lightly brush your palms across your nipples for 2 minutes.”
"Do not eat or drink anything for 4 hours prior to the test.”
"Press the button you are given when you feel the baby moving during the test.”
The Correct Answer is D
Choice A reason:
The nurse should not tell the client to lie flat on their back for the duration of the nonstress test. It is essential for pregnant clients to be in a semi-reclining or left lateral position during the test to avoid supine hypotension syndrome. This condition can occur when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and potentially compromising the baby's well-being.
Choice B reason:
The nurse should not instruct the client to lightly brush their palms across their nipples during the test. This statement is not related to the nonstress test procedure. The nonstress test involves monitoring the baby's heart rate in response to its movements, and nipple stimulation is not a standard part of the test.
Choice C reason:
The nurse should not advise the client not to eat or drink anything for 4 hours before the test. It is important for pregnant clients to have adequate nutrition and hydration, especially during the third trimester. Restricting food and drink for such a prolonged period could lead to dehydration and may not be necessary for the test.
Choice D reason:
This is the correct choice. During a nonstress test, the client is connected to a fetal heart rate monitor. They are asked to press a button whenever they feel the baby moving. This allows the healthcare provider to correlate the baby's movements with changes in the heart rate pattern, which helps assess the baby's well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
Breast changes are considered a presumptive sign of pregnancy. This means they are subjective indications reported by the woman and may not be definitive evidence of pregnancy. During pregnancy, the woman's breasts may undergo various changes such as tenderness, enlargement, and darkening of the areolas. These changes are primarily due to hormonal fluctuations and increased blood flow to the breast tissue.
Choice B reason:
Ballottement is not a presumptive sign of pregnancy. Ballottement is a clinical maneuver performed by a healthcare provider to assess the mobility of the fetus in the amniotic fluid. It involves tapping on the cervix and feeling for a rebound from the floating fetus. While it is an indication of pregnancy, it is not considered a presumptive sign as it requires a trained professional to detect.
Choice C reason:
Urinary frequency is a presumptive sign of pregnancy. During pregnancy, the growing uterus can put pressure on the bladder, leading to increased urinary frequency. However, urinary frequency can also be caused by other factors such as urinary tract infections, so it is not a definitive sign of pregnancy.
Choice D reason:
Nausea, specifically morning sickness, is a presumptive sign of pregnancy. Many pregnant women experience nausea and vomiting, especially during the first trimester, due to hormonal changes. However, nausea can also be caused by various other conditions, making it a presumptive rather than a confirmatory sign of pregnancy.
Choice E:
A positive pregnancy test is a probable sign of pregnancy rather than a presumptive sign. Pregnancy tests detect the presence of human chorionic gonadotropin (hCG), a hormone produced during pregnancy. A positive test provides strong evidence of pregnancy, but it is not considered a presumptive sign as it is an objective finding rather than a subjective symptom reported by the woman.
Correct Answer is B
Explanation
Choice A reason:
If the parent states, "My child uses scissors to cut out the outline of an object,” this indicates fine motor skills development. While this is a positive milestone, it is not specific to the expected benchmarks of other preschoolers in this age group. The ability to cut out shapes with scissors varies widely among preschoolers.
Choice B reason:
"My child can copy triangle shapes onto paper.” This statement shows that the child can demonstrate some level of visual-motor coordination and fine motor skills. Copying shapes like triangles is a common milestone for many preschoolers at the age of 3 and is considered an expected benchmark.
Choice C reason:
If the parent says, "My child can ride a tricycle,” this indicates gross motor skills development. Riding a tricycle is also a milestone achieved by many preschoolers, but it may not be as specific to the expected benchmarks of this age group as choice B, which focuses on fine motor skills and visual-motor coordination.
Choice D reason:
If the parent mentions, "My child can throw a ball overhead,” this also points to gross motor skills development. While throwing a ball overhead is an impressive skill for a 3-year-old, it may not be as common or consistent among all preschoolers in this age group as the ability to copy triangle shapes onto paper (choice B).
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