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 A

Explanation

The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.

Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.

Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.

It usually resolves within 24 to 48 hours after birth.

Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.

It usually disappears by 6 months of age.

Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.

It usually fades by 4 months of age.

A. “I should expect a few spots of blood on my underwear because I have more blood in my body now.”. B. “Clear fluid will leak from my vagina if my baby is surrounded by too much water in my womb.”. C. “If I begin to see dark patches on my face, it means that my blood pressure is rising.”. D. “If I feel like I have butterflies in my stomach, it means my baby is moving.”.

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.

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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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Correct Answer is A

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Correct Answer is D

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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?