A nurse is reinforcing teaching with a client who is at weeks of gestation and scheduled for a non-stress 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
I have to lie on my back during the test
The baby’s heart rate will be monitored during the test
I will be able to go to the bathroom during the test if necessary
The Correct Answer is B
Rationale for Choice A:
It is accurate that scheduling the NST when the baby is usually active is beneficial. This is because fetal movement is expected to cause accelerations in the fetal heart rate, which is a positive sign of fetal well-being.
By scheduling the test during a time of typical fetal activity, the chances of obtaining a reactive NST (a normal result) are increased.
Therefore, this statement does not indicate a need for further teaching.
Rationale for Choice B:
Lying on the back during the NST is not recommended.
This position can cause the weight of the uterus to compress the major blood vessels (the inferior vena cava and aorta), potentially reducing blood flow to the placenta and fetus.
Reduced blood flow can, in turn, lead to a decrease in fetal heart rate and movement.
To avoid this, the recommended position for NST is a semi-Fowler's position, which involves being partially reclined with the head and upper body elevated.
This position helps to promote uterine perfusion and prevent supine hypotension.
Rationale for Choice C:
It is accurate that the baby's heart rate will be monitored during the NST.
This is the primary purpose of the test: to assess the fetal heart rate response to fetal movement. Therefore, this statement does not indicate a need for further teaching.
Rationale for Choice D:
It is accurate that the client will be able to go to the bathroom during the NST if necessary. The test is noninvasive and does not require strict immobility.
The client can move around and use the bathroom as needed, as long as the fetal heart rate monitor is not disconnected.
Therefore, this statement does not indicate a need for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Ovarian cysts are fluid-filled sacs that form on or within an ovary. They are a common condition, affecting up to 1 in 5 women at some point in their lives. While most ovarian cysts are benign (non-cancerous), they can sometimes cause symptoms, including pelvic pain.
Ultrasound is a common imaging test that uses sound waves to create pictures of internal organs. It can be used to detect ovarian cysts, which often appear as fluid-filled sacs on the ovary.
The presence of an ovarian cyst on ultrasound, combined with the patient's symptoms of lower abdominal pelvic pain, suggests that the patient is at risk of developing complications from the cyst. These complications can include: Rupture: A ruptured ovarian cyst can cause sudden, severe pain and bleeding.
Torsion: This is when a cyst twists on its stalk, cutting off its blood supply. Torsion can also cause severe pain and may require emergency surgery.
Choice B rationale:
Appendicitis is an inflammation of the appendix, a small, finger-shaped organ located in the lower right abdomen. It is a common cause of abdominal pain, especially in young adults.
However, the patient in this scenario is experiencing pain in the lower abdominal pelvic region, not specifically in the lower right quadrant. This makes appendicitis less likely.
Additionally, the patient does not have any other symptoms that are typically associated with appendicitis, such as fever, nausea, or vomiting.
Choice C rationale:
Endometriosis is a condition in which tissue that normally lines the uterus grows outside of the uterus. It can cause pain, especially during menstruation.
However, the patient in this scenario does not report cyclical pain, which is a hallmark symptom of endometriosis. Additionally, endometriosis is not typically associated with the presence of fluid-filled sacs on the ovaries.
Choice D rationale:
Pelvic inflammatory disease (PID) is an infection of the upper genital tract, including the uterus, fallopian tubes, and ovaries. It is often caused by sexually transmitted infections (STIs).
PID can cause pelvic pain, but it is also typically associated with other symptoms, such as fever, vaginal discharge, and irregular bleeding.
The patient in this scenario does not have any of these other symptoms, and her white blood cell count is not elevated, which makes PID less likely.
Correct Answer is A
Explanation
The correct answer is choiceA. Here are the rationales for each choice:
Choice A rationale:
Emptying the bladder immediately prior to the procedure is recommended to reduce the risk of bladder puncture during the amniocentesis. A full bladder can obstruct the procedure and increase the risk of complications.
Choice B rationale:
Washing the abdomen with soap and water the morning of the procedure is not specifically required for amniocentesis.Standard hygiene practices are sufficient.
Choice C rationale:
Giving herself a hypertonic enema the day before the procedure is not necessary and is not recommended.There is no need for bowel preparation before an amniocentesis.
Choice D rationale:
Refraining from eating breakfast the day of the procedure is not required.Patients can eat and drink as normal before the procedure.
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