A nurse is teaching a client who is pregnant about nonstress testing. Which of the following statements by the client indicates an understanding of the teaching?
"This test will tell me if my baby has a genetic problem."
"I will get oxytocin during this test."
"During this test. I must not eat or drink anything."
"During this test. I will push a button if my baby moves."
The Correct Answer is D
D. "During this test, I will push a button if my baby moves."
Rationale:
A. "This test will tell me if my baby has a genetic problem." - Nonstress testing (NST) is used to evaluate fetal well-being by assessing fetal heart rate accelerations in response to fetal movement. It does not diagnose genetic problems.
B. "I will get oxytocin during this test." - Oxytocin is not typically administered during nonstress testing. NST is a non-invasive procedure that involves placing a fetal heart rate monitor on the mother's abdomen to monitor the baby's heart rate.
C. "During this test, I must not eat or drink anything." - While it's generally recommended to have a snack or meal before the test to encourage fetal movement, fasting is not required for NST unless otherwise instructed by the healthcare provider.
D. "During this test, I will push a button if my baby moves." - This statement demonstrates an understanding of how NST works. The client is instructed to push a button whenever they feel fetal movement, allowing the healthcare provider to correlate fetal movement with changes in the fetal heart rate pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.
Correct Answer is B
Explanation
A. The client's heart rate increases by 10/min: An increase in heart rate upon changing positions may occur as a compensatory mechanism to maintain blood pressure, but it is not indicative of orthostatic hypotension. Orthostatic hypotension is characterized by a decrease in blood pressure upon assuming an upright position.
B. The client's systolic blood pressure decreases by 25 mm Hg: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing up from a supine position. Therefore, a decrease in systolic blood pressure by 25 mm Hg upon changing positions is consistent with orthostatic hypotension.
C. The client's diastolic blood pressure increases by 10 mm Hg: Orthostatic hypotension typically involves a decrease in both systolic and diastolic blood pressure upon assuming an upright position. An increase in diastolic blood pressure is not consistent with orthostatic hypotension.
D. The client reports heart palpitations: Heart palpitations may occur due to various reasons, such as anxiety or cardiac arrhythmias, but they are not specific to orthostatic hypotension. While orthostatic hypotension may cause symptoms like dizziness or lightheadedness, heart palpitations are not typically associated with this condition.
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