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

Braxton Hicks contractions are irregular, painless uterine contractions that occur throughout pregnancy, but are more noticeable in the third trimester.They do not indicate labor, but rather help in softening and ripening the cervix.

Choice A is wrong because the patient does not need to time the contractions unless they become regular, painful, and closer together, which are signs of true labor.

Choice B is wrong because documenting fetal activity daily is not related to Braxton Hicks contractions.Fetal activity is monitored to assess fetal well-being and detect any signs of fetal distress.

Choice C is wrong because losing the mucus plug is also not related to Braxton Hicks contractions.The mucus plug is a thick plug of mucus that seals the cervical canal during pregnancy and may be expelled before or during labor.

A. It is necessary to promote muscle tone to minimize acrocyanosis. B. It is necessary to encourage tactile stimulation to promote the myelinization of nerves. C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother. D. When reflexes are stimulated in the neonate, a normal growth pattern ensues.

Correct Answer is C

Explanation

The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.

Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.

Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.

Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.

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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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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?