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 D
Explanation
The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.
This is a normal and expected change during pregnancy, especially in the second and third trimesters.The baby’s movements can be felt as flutters, kicks, or rolls.
Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.
It can indicate a problem such as placenta previa, placental abruption, or miscarriage.Any bleeding during pregnancy should be reported to the health care provider.
Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.
It can indicate that the membranes have ruptured and amniotic fluid is escaping.
This can lead to infection and preterm labor if not treated promptly.Any fluid leakage during pregnancy should be reported to the health care provider.
Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.
They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes.They usually fade after delivery and are not harmful.High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.
Correct Answer is C
Explanation
The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.
Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.
Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.
Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.
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