A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching?
"You should massage one of your nipples to stimulate contractions of your uterus."
"You will have a Doppler transducer applied to your abdomen during the test.
"You should avoid eating or drinking for 4 hours before the test."
"You will need blood work before and after the test."
The Correct Answer is B
A. "You should massage one of your nipples to stimulate contractions of your uterus.": Nipple stimulation is used to induce contractions during a contraction stress test, not a nonstress test. For a nonstress test, the goal is to assess fetal heart rate in response to fetal movements without inducing contractions.
B. "You will have a Doppler transducer applied to your abdomen during the test.": A nonstress test involves placing a Doppler transducer on the maternal abdomen to monitor fetal heart rate and a tocodynamometer to detect uterine activity. The test is noninvasive and monitors fetal heart rate accelerations in response to movement.
C. "You should avoid eating or drinking for 4 hours before the test.": Fasting is not required for a nonstress test. In fact, some providers encourage eating beforehand to promote fetal activity, which helps obtain accurate heart rate accelerations.
D. "You will need blood work before and after the test.": Blood work is not required for a nonstress test. The test relies solely on external monitoring of the fetal heart rate and maternal contractions, making it noninvasive and straightforward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.
B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.
C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.
D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.
Correct Answer is B
Explanation
A. Discuss the client's strengths and weaknesses with the client: Exploring strengths can be part of long‑term therapeutic support, but it does not address the immediate concern of a possible suicidal statement. Before engaging in broader discussions, the nurse must first determine the meaning and seriousness of the client’s words.
B. Ask the client to clarify what they mean: Asking the client to clarify their statement is the priority because it directly assesses the risk of self‑harm. This step helps the nurse determine whether the client has suicidal ideation, intent, or a plan. Clear assessment of safety concerns must occur before any other supportive or therapeutic interventions.
C. Ask the client if they have been taking their medication as prescribed: Medication adherence is important, but it does not address the urgency of a suicidal comment. Focusing on medications can divert attention from immediate safety needs and delay critical assessment of suicidal risk.
D. Remind the client that it is not the end of life: Offering reassurance without assessing the client’s emotional state can minimize their feelings and discourage further communication. This response may shut down dialogue and does not evaluate the level of risk, which is the most urgent priority.
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