A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

The client will be asked to stimulate her nipples for 5 min during the test.

An external fetal monitor will be used to monitor the FHR.

An IV will be initiated prior to the test.

The client will receive an ultrasound prior to the test.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Stimulating nipples is not typically part of a nonstress test procedure.

B. An external fetal monitor will be used to monitor the fetal heart rate (FHR) during the nonstress test. This is the main purpose of the test, to assess the fetal heart rate in response to fetal movement.

C. An IV is not typically initiated for a nonstress test unless there are specific medical indications.

D. An ultrasound is not typically performed prior to a nonstress test unless additional fetal assessment is needed. The nonstress test primarily involves monitoring the fetal heart rate using an external fetal monitor.

Nursing Test Bank

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Correct Answer is B

Explanation

Rationale:

A. Threatened abortion is characterized by vaginal bleeding, but it is typically associated with pain or cramping. The bleeding in placenta previa is painless.

B. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. Bright red vaginal bleeding in the third trimester is a hallmark sign of placenta previa.

C. Abruptio placentae is characterized by painful vaginal bleeding due to premature separation of the placenta from the uterine wall.

D. Preterm labor is associated with regular uterine contractions and cervical changes, rather than painless vaginal bleeding.

A. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines. B. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines. C. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines. D. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines.

Correct Answer is C

Explanation

A: The presenting part being 1 cm below the ischial spines would be indicated by a positive number, not negative.
B: The documentation does not indicate effacement in centimeters, and dilation is not typically expressed in percentages.
C: The cervix is dilated 3 cm (the opening width), effaced 30% (the thinning percentage), and the presenting part is at -1 station, which means it is 1 cm above the ischial spines.
D: Similar to choice B, the documentation does not indicate effacement in centimeters, and dilation is not typically expressed in percentages. Additionally, the presenting part being above the ischial spines is correctly indicated by a negative number, not positive.

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A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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