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 C

Explanation

The correct answer is choice C.Choice C is wrong because having more than three full-term pregnancies does not affect the suitability of using a copper IUD as a birth control method.Copper IUDs are long-term, reversible contraceptives that can be used by premenopausal women of all ages, including those who have never been pregnant or who have had multiple pregnancies.

Choice A is correct because a copper IUD can be inserted anytime during a normal menstrual cycle, or up to eight weeks after childbirth.

Choice B is correct because a copper IUD may cause heavier and longer periods, as well as more cramping.

Choice D is correct because a copper IUD works by creating an inflammatory response in the uterus that prevents sperm from reaching the egg and fertilizing it, and also prevents a fertilized egg from implanting in the uterine wall.

A. “I will begin to practice pelvic tilt exercises.”. B. “I will wear shoes with low heels when I go to work.”. C. “I will sleep on my side with a pillow beneath my knees.”. D. “I will lean slightly backwards when I walk.”.

Correct Answer is D

Explanation

The correct answer is choice D. Leaning slightly backwards when walking can increase the curvature of the lower spine and worsen back pain.

The other choices are helpful methods to alleviate back pain during pregnancy.

Choice A is correct because pelvic tilt exercises can strengthen the abdominal muscles and reduce the strain on the lower back.

Choice B is correct because wearing shoes with low heels can improve posture and balance and prevent excessive arching of the lower back.

Choice C is correct because sleeping on the side with a pillow beneath the knees can support the spine and pelvis and relieve pressure on the lower back.

Normal ranges for back pain during pregnancy vary depending on the individual, but some common factors that can affect it are weight gain, hormonal changes, center of gravity shift, stress and muscle separation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing information to a patient regarding contraception methods. Which statement by the patient indicates a need for further teaching regarding use of copper intrauterine device (IUD)?

Correct Answer is C

Explanation

During a class for women in the second trimester of pregnancy, the nurse discusses methods to alleviate back pain. Which statement by a class member would indicate the need for additional instruction?

Correct Answer is D

Explanation

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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?