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. Empty your bladder prior to the test.This is because a full bladder can interfere with the insertion of the needle and increase the risk of complications.Amniocentesis is a test that involves removing and testing a small sample of cells from amniotic fluid, the fluid that surrounds the baby in the womb.It is done to check for genetic or chromosomal conditions, such as Down’s syndrome, Edwards’ syndrome or Patau’s syndrome.
Choice A is wrong because there is no need to remain flat in bed for six hours after the test.You can resume your normal activities after a few hours of rest.
Choice B is wrong because vaginal bleeding is not a normal outcome of amniocentesis.If you experience any bleeding, leaking of fluid, fever or severe pain after the test, you should contact your doctor immediately.
Choice D is wrong because there is no restriction on eating before the test.You can have your normal meals and drinks before amniocentesis.
Correct Answer is A
Explanation
A rubella titer of 1:33 indicates a low level of immunity to rubella, which can be dangerous for a pregnant woman and her fetus.
Rubella is a viral infection that can cause birth defects or miscarriage if contracted during pregnancy.A rubella titer of 1:10 or higher is considered protective.
Choice B is wrong because a non-reactive serologic test for syphilis (STS) means that the patient does not have syphilis, which is a bacterial infection that can also harm the fetus if untreated.
Choice C is wrong because blood type A-negative does not require further assessment unless the patient has antibodies to the Rh factor, which can cause hemolytic disease of the newborn if the fetus is Rh-positive.
This can be prevented by giving the patient Rh immunoglobulin injections during pregnancy and after delivery.
Choice D is wrong because hemoglobin 12.2 gm/dL is within the normal range for a pregnant woman, which is 11 to 14 gm/dL.
Hemoglobin is the protein in red blood cells that carries oxygen.
A low hemoglobin level can indicate anemia, which can affect the oxygen delivery to the fetus and increase the risk of preterm labor or low birth weight.
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