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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Related Questions
Correct Answer is C
Explanation
Choice A reason:
The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.
Choice B reason:
The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.
Choice C reason:
Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.
Choice D reason:
The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.
Correct Answer is C
Explanation
"I should call my provider if I notice thick white discharge in my underwear.”
Choice A reason:
The client stating, "I will need to have this device replaced every 3 years,” is incorrect. Subdermal progesterone contraception devices, such as Nexplanon, can typically last for up to 3 years, not needing replacement within that time frame. The rationale behind this is that these devices release a steady amount of progesterone to prevent pregnancy, and they are designed to be effective for the specified duration.
Choice B reason:
The statement, "This device will protect me from STIs,” in Choice B is incorrect. Subdermal progesterone contraception devices do not provide protection against sexually transmitted infections (STIs). Their primary function is to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering the uterine lining, but they do not offer any defense against STIs. It is essential for the client to understand that barrier methods, such as condoms, are necessary for STI protection.
Choice C reason:
The correct answer, "I should call my provider if I notice thick white discharge in my underwear,” is an accurate statement. Thick white discharge could be indicative of a vaginal infection, such as yeast infection, which might require medical attention. It is crucial for the client to report any changes in vaginal discharge to their healthcare provider for proper evaluation and treatment.
Choice D reason:
The statement in Choice D, "I need to decrease the amount of milk I drink while I have this device,” is incorrect. There is no association between subdermal progesterone contraception devices and milk consumption. The device does not interfere with dairy intake or affect its metabolism. This information is unrelated to the proper use or management of the contraception device.
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