A patient who is 36 weeks pregnant tells you she has been counting her baby's kicks and is concerned because within a 4-hour period the baby has only kicked 32 times.
What nursing intervention is correct?
Assess the patient's urine for protein and glucose.
Prep the patient for an abdominal ultrasound.
Reassure the patient this kick count is normal.
Notify the MD of this finding.
The Correct Answer is D
Choice A rationale
Assessing the patient's urine for protein and glucose is relevant for evaluating potential preeclampsia or gestational diabetes, but it does not directly address the immediate concern of decreased fetal movement. While these conditions can indirectly affect fetal well-being, the priority is to assess fetal status directly.
Choice B rationale
Preparing the patient for an abdominal ultrasound can provide information about fetal well-being and amniotic fluid volume, but it is not the immediate first-line intervention for a concerning decrease in fetal kick counts. Further assessment is needed before resorting to diagnostic procedures.
Choice C rationale
A kick count of 32 movements in 4 hours is below the generally accepted normal range. While definitions vary slightly, many healthcare providers consider fewer than 10 movements in 2 hours or a significant decrease from the patient's baseline to be concerning and warrant further investigation. Reassuring the patient without further assessment would be inappropriate.
Choice D rationale
A decrease in fetal movement can be a sign of fetal distress and requires prompt evaluation by a healthcare provider. Notifying the physician or midwife is the correct priority nursing intervention to initiate further assessment of fetal well-being, which may include a non-stress test (NST) or biophysical profile (BPP).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increasing ambulation is generally encouraged in the postpartum period to prevent complications like thrombophlebitis, but it does not address the potential cause of foul-smelling lochia. Foul odor is a key indicator of infection, and ambulation will not resolve an existing infection.
Choice B rationale
Increasing oral fluids is important for hydration in the postpartum period, but it will not directly address a foul-smelling odor in the lochia. While adequate hydration supports overall healing, it does not treat an infection. A foul odor strongly suggests a localized infectious process in the uterus.
Choice C rationale
Lochia that is red (rubra) is normal in the first few days postpartum. However, a foul-smelling odor is an abnormal finding and a significant indicator of a potential uterine infection, also known as endometritis or puerperal infection. Further assessment and intervention are required to identify and treat the infection.
Choice D rationale
Normal lochia progresses from rubra (red) to serosa (pinkish-brown) to alba (yellowish-white) over several weeks postpartum. Normal lochia should have a fleshy, not foul, odor. A foul smell is an abnormal finding that suggests an infectious process within the uterus and requires prompt attention.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. Symptoms can include unilateral abdominal pain, light to heavy vaginal bleeding, and a positive pregnancy test. An ectopic pregnancy is a serious condition requiring prompt medical attention.
Choice B rationale
Molar pregnancy, also known as gestational trophoblastic disease, is characterized by abnormal growth of trophoblasts, the cells that normally develop into the placenta. It can present with symptoms such as vaginal bleeding (ranging from spotting to heavy bleeding), pelvic pain or pressure, and a uterus that may be larger than expected for the gestational age. The absence of a fetal heartbeat and elevated hCG levels are also characteristic.
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