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. Reminding her that she should be happy that one child survived and is healthy is the least helpful nursing action in supporting the woman as she copes with her loss.
This statement minimizes her grief and implies that she should not feel sad about the deceased twin.
It also disregards her attachment to both babies and her need to mourn the loss of one of them.
Choice A is wrong because offering her the opportunity for counseling to help her grieve is a helpful nursing action that recognizes her emotional distress and provides her with professional support.
Choice B is wrong because encouraging the woman to hold the deceased twin as well as the living twin is a helpful nursing action that allows her to acknowledge and bond with both babies and to create memories that may facilitate healing.
Choice D is wrong because assisting the woman to take pictures of both babies is a helpful nursing action that provides her with tangible mementos of her twins and honors their
Correct Answer is C
Explanation
The correct answer is choice C. Arrange for her to meet the staff who will be caring for her during labor and delivery.This measure can help reduce the anxiety and fear of the unknown that a primigravida may have in the last month of pregnancy.Meeting the staff can also help establish rapport and trust, which are essential for a positive birth experience.
Choice A is wrong because an increase in fetal activity does not necessarily require an increase in the need to rest.
Fetal activity is normal and expected, and the mother should monitor it regularly.Resting may help with some discomforts of pregnancy, but it is not directly related to fetal activity.
Choice B is wrong because back labor is not likely for a primigravida with an uncomplicated pregnancy.
Back labor occurs when the fetus is in an occiput posterior position, which puts pressure on the mother’s spine and causes intense pain in the lower back.This position is more common in multiparous women than primigravidas.
Choice D is wrong because testing urine for glucose is not a routine measure for a primigravida with an uncomplicated pregnancy.
Urine glucose testing is done for women who have gestational diabetes or are at risk of developing it.It is not necessary for women who have normal blood glucose levels.
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