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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D: “This test is used to identify fetal abnormalities.” Alpha-fetoprotein (AFP) is a protein produced by the fetus that can be measured in the mother’s blood.

Abnormal levels of AFP may indicate a problem with the development of the baby’s brain, spine, or other organs.

This test is usually done between 15 and 20 weeks of gestation.

Choice A is wrong because AFP does not measure the baby’s maturity.

It is not related to the gestational age or the lung development of the fetus.

Choice B is wrong because AFP is not a routine test for all pregnant women over thirty years of age.

It is an optional screening test that may be offered to women who have a higher risk of having a baby with a birth defect, such as those who have a family history, a previous affected pregnancy, or certain ethnic backgrounds.

Choice C is wrong because AFP is not recommended for people with a history of infertility.

It does not assess the fertility status of the mother or the father.

It only measures the level of a fetal protein in the mother’s blood.

A. They need less supplemental iron than women who have been menstruating longer because their reserves are generally greater. B. They have less need for simple carbohydrates than older women because they are able to convert fat stores into usable glucose. C. Their need for protein exceeds that of pregnant women over 20 years of age. D. Their need for vitamin C is greater than that of pregnant women over 20 years of age.

Correct Answer is C

Explanation

The correct answer is choice C.Adolescents need more protein than older pregnant women because they are still growing themselves and need to support the growth of the baby and the placenta.Protein can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.

Choice A is wrong because adolescents need more supplemental iron than older women, not less.This is because they have lower iron stores due to rapid growth and menstruation.Iron deficiency can cause anemia and increase the risk of infections and bleeding.Iron can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.

Choice B is wrong because adolescents need more carbohydrates than older women, not less.Carbohydrates provide energy for the mother and the baby and spare protein for other functions.Carbohydrates can be found in grains, fruits, vegetables, and dairy products.

Choice D is wrong because adolescents need the same amount of vitamin C as older pregnant women, which is 85 milligrams per day.Vitamin C helps with wound healing, collagen formation, iron absorption, and immune function.Vitamin C can be found in citrus fruits, tomatoes, peppers, broccoli, potatoes, and fortified juices.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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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?