A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

Avoid caffeinated drinks for 24 hours before conducting the kick test.

Exercise for 15 minutes before starting the counting to help increase fetal movement.

Count the movements once daily, for one hour, before breakfast.

If 10 kicks are not felt within one hour, drink orange juice and count for another hour.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine does not significantly affect fetal movements.

Choice B rationale

Exercising for 15 minutes before starting the counting to help increase fetal movement is not a standard recommendation. While physical activity can sometimes stimulate fetal movement, it’s not a requirement for performing kick counts.

Choice C rationale

Counting the movements once daily, for one hour, before breakfast is not the standard recommendation. The best time to do kick counts is when the baby is usually most active, which might be after a meal, early in the morning, or at another point in the day.

Choice D rationale

If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn’t feel 10 movements within 2 hours, she should contact her healthcare provider.

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Correct Answer is C

Explanation

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

A. Encourage the mother to breastfeed more frequently. B. Monitor the neonate’s stool and urine output for the last 24 hours. C. Reassure the mother that this is a normal weight loss. D. After verifying the weight’s accuracy, inform the healthcare provider.

Correct Answer is C

Explanation

Choice A rationale

While breastfeeding more frequently can be beneficial for the mother-infant bonding and milk production, it does not directly address the infant’s weight loss.

Choice B rationale

Monitoring the neonate’s stool and urine output for the last 24 hours can provide information about the infant’s hydration status. However, it does not directly address the concern of weight loss.

Choice C rationale

It is normal for newborns to lose some weight in the first few days after birth. This is often due to the loss of excess fluid. A weight loss of up to 10% of the birth weight is generally considered normal in the first week.

Choice D rationale

While it’s important to verify the accuracy of the weight measurement, informing the healthcare provider is not the immediate action required if the weight loss is within the normal range.

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A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

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