A nurse is teaching a client who is scheduled for a non-stress test. Which of the following information should the nurse include? Choice Options:

An IV will be initiated prior to the test.

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

The client will receive an ultrasound prior to the test.

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

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:
An IV is not routinely initiated prior to a non-stress test. It may be started if a biophysical profile (BPP), which includes an ultrasound, is also being performed, or if there is a risk of complications that may necessitate immediate intervention. However, it is not a standard part of the non-stress test itself.

Rationale for Choice B:
Nipple stimulation is not a standard component of a non-stress test. It may be used in some cases to try to induce fetal movement if the fetus is not moving actively enough during the test. However, it is not a routine part of the procedure.

Rationale for Choice C:
An ultrasound is not typically performed prior to a non-stress test. It may be done as part of a BPP, but it is not necessary for the non-stress test itself.

Rationale for Choice D:
An external fetal monitor is essential for conducting a non-stress test. This monitor uses two belts that are placed around the mother's abdomen. One belt measures the fetal heart rate, and the other belt measures uterine contractions. The monitor records the fetal heart rate and any contractions for a period of 20 to 40 minutes. The test is considered reactive (normal) if the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice during the test. This acceleration in heart rate is typically in response to fetal movement.

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Correct Answer is B

Explanation

The correct answer is choice b. Placenta previa.

Choice A rationale:

Threatened abortion typically occurs in the first trimester and involves vaginal bleeding with or without abdominal pain. It is not associated with late pregnancy bleeding.

Choice B rationale:

Placenta previa is characterized by painless, bright red vaginal bleeding in the third trimester. It occurs when the placenta covers the cervix, leading to bleeding as the cervix begins to dilate.

Choice C rationale:

Preterm labor involves uterine contractions leading to cervical changes before 37 weeks of gestation. While it can cause bleeding, it is usually accompanied by regular contractions and not typically described as bright red bleeding.

Choice D rationale:

Abruptio placentae involves the premature separation of the placenta from the uterine wall, leading to painful, dark red vaginal bleeding. It is often associated with abdominal pain and uterine tenderness, which differentiates it from placenta previa.

A. Apply ice to the perineal area. B. Apply an external fetal monitor. C. Complete a vaginal exam. D. Perform a rectal exam.

Correct Answer is B

Explanation

Choice A:
Applying ice to the perineal area is not a recommended intervention for suspected placenta previa. While ice can help reduce swelling and pain in some cases, it does not address the underlying concern of potential placental bleeding.
Focusing on external monitoring for fetal well-being and avoiding any actions that could disrupt the placenta are the priorities in this situation.

Choice C:
Completing a vaginal exam is contraindicated in suspected placenta previa. Inserting fingers into the vagina can disrupt the placenta and potentially cause heavy bleeding, increasing the risk of preterm labor, fetal distress, or maternal hemorrhage. Non-invasive assessment methods are crucial to protect the placenta and prevent complications.

Choice D:
Performing a rectal exam is also not indicated for suspected placenta previa. It does not provide information about the placental position and could potentially stimulate contractions, which are undesirable in this situation.
External fetal monitoring is a safer and more informative approach.

Choice B:
Applying an external fetal monitor is the most appropriate action for a nurse caring for a client with suspected placenta previa. It allows for continuous assessment of fetal heart rate and activity, which can help detect any signs of fetal distress or placental abruption.
It is a non-invasive method that does not carry the risks associated with vaginal or rectal exams.
Early identification of any fetal compromise can lead to prompt interventions to ensure the best possible outcomes for both mother and baby.

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A nurse is teaching a client who is scheduled for a non-stress test. Which of the following information should the nurse include? Choice Options:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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