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
While blood pressure can increase during the second trimester due to changes in the maternal cardiovascular system, it doesn't typically increase *early* in the second trimester. Physiologic changes usually lead to a slight decrease in blood pressure during the first and early second trimester before gradually returning to pre-pregnancy levels or potentially increasing later.
Choice B rationale
While multiparous women can develop gestational hypertension or preeclampsia, having had "several pregnancies" in the past does not inherently increase the risk of high blood pressure at 14 weeks gestation in the current pregnancy, especially if previous pregnancies were normotensive. Risk factors like age, pre-existing conditions, and family history are more significant.
Choice C rationale
Advanced maternal age, generally considered 35 years or older, is a known risk factor for developing gestational hypertension and preeclampsia during pregnancy. Physiological changes associated with aging can affect vascular function and increase susceptibility to hypertensive disorders.
Choice D rationale
While addressing the client's feelings is important for therapeutic communication, it avoids answering her direct question about why her blood pressure is being taken. The nurse has a responsibility to provide accurate information regarding routine assessments during pregnancy.
Correct Answer is ["B","F","G"]
Explanation
Choice B rationale
Prostaglandin administration, either vaginally or orally, helps to ripen the cervix by increasing collagenase activity and water content, leading to cervical softening, thinning (effacement), and dilation, which are necessary for labor to begin.
Choice F rationale
Amniotomy, or artificial rupture of membranes (AROM), involves the deliberate rupture of the amniotic sac. This can stimulate labor by releasing prostaglandins, increasing uterine contractility, and allowing the presenting part of the fetus to descend further into the pelvis, putting pressure on the cervix.
Choice G rationale
Oxytocin is a synthetic hormone that mimics the action of endogenous oxytocin, stimulating uterine contractions. It is commonly administered intravenously to initiate or augment labor once cervical ripening has occurred or the cervix is favorable.
Choice A rationale
Epidural anesthesia is a method of pain relief during labor, not a method for inducing labor. It provides regional analgesia by blocking nerve impulses in the lower body.
Choice C rationale
Bed rest is generally not recommended for labor induction and can even be counterproductive. Ambulation and positional changes can help to encourage fetal descent and uterine activity.
Choice D rationale
Vitamin supplementation is important for overall maternal and fetal health during pregnancy but does not directly stimulate uterine contractions or cervical changes necessary for labor induction.
Choice E rationale
Fetal ultrasound is used to assess fetal well-being, presentation, and amniotic fluid volume but does not initiate the process of labor induction. .
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