A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143.
Which action should the nurse take?
Ask the patient if she has had any alcoholic beverages within the past 24 hours.
Find out if the patient has had any bloody vaginal discharge today.
Tell the patient that the fetal heart rate does not appear to indicate that the baby is in distress.
Explain to the patient the relationship between a woman's anxiety level and her ability to detect movement.
The Correct Answer is C
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The woman’s temperature will increase when she is ovulating.This is because ovulation is triggered by a surge of luteinizing hormone (LH), which also causes a slight rise in basal body temperature (BBT).By measuring her BBT every morning before getting out of bed, the woman can detect this subtle change and identify her fertile window.
Choice A is wrong because ovulation typically occurs around 14 days before the next menstrual period, not seven days after the previous one.
The length of the menstrual cycle can vary from woman to woman, so counting days is not a reliable method of predicting ovulation.
Choice B is wrong because cervical mucus will appear clear, slippery and stretchy when the woman is ovulating, not tacky and cloudy.
This type of mucus helps sperm swim and survive in the reproductive tract.
The woman can check her cervical mucus by wiping with toilet paper or inserting a finger into her vagina.
Choice D is wrong because abdominal massage of the ovaries will not stimulate ovulation, and may even cause harm by injuring the delicate tissues or introducing infection.
Correct Answer is C
Explanation
The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.
This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.
The duration is measured from the start of one contraction until the end of that same contraction.
Choice A is wrong because it measures the frequency of contractions, not the duration.
The frequency is the time between the start of one contraction and the start of the next one.
Choice B is wrong because it measures only half of the duration of a contraction.
The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.
Choice D is wrong because it measures both the duration and the interval of contractions.
The interval is the time between the end of one contraction and the start of the next one.
Normal ranges for contractions during labor are:
• Duration: 30 to 90 seconds
• Frequency: 2 to 5 minutes apart
• Interval: 30 to 120 seconds
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