The nurse is teaching a pregnant client how to perform daily fetal movement counts.
Which instruction must be included in the teaching?
Lie on back when counting kicks.
You can begin counting fetal movements at 8 weeks gestation.
Call healthcare provider if at least 3 movements are not felt over an hour.
Count movements at the same time each day.
The Correct Answer is C
Choice A rationale
Lie on back when counting kicks is incorrect. It is recommended to lie on the side, preferably the left side, as lying on the back can compress major blood vessels and affect circulation to the fetus.
Choice B rationale
You can begin counting fetal movements at 8 weeks gestation is incorrect. Fetal movements are typically felt by the mother starting around 18-20 weeks of gestation, not as early as 8 weeks.
Choice C rationale
Call healthcare provider if at least 3 movements are not felt over an hour. This is an important guideline as decreased fetal movements can indicate potential issues and should be reported to the healthcare provider for further evaluation.
Choice D rationale
Count movements at the same time each day is a good practice but it is not the most critical instruction. While consistency is beneficial, the immediate action for decreased movements is more urgent.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Obtaining the client's personal and family medical history is essential during the initial prenatal visit. This history helps identify any genetic disorders or chronic conditions that might affect the pregnancy. It also provides insight into the client's overall health and any potential risk factors.
Choice B rationale
Information about prior pregnancies is important but not the first priority. Prior pregnancy information can provide insights into previous complications, but a comprehensive medical history should come first.
Choice C rationale
Checking the client's urine with a reagent strip is not the primary action during an initial visit. Urine tests are useful for detecting infections and certain conditions, but they come after a thorough history has been obtained.
Choice D rationale
Scheduling the client for prenatal laboratory testing is necessary, but it follows the initial assessment and history-taking. Laboratory tests help confirm the pregnancy and assess overall health but are not the first step.
Choice E rationale
Discussing chorionic villus sampling (CVS) is premature at this stage. CVS is a prenatal test conducted around 10-13 weeks for detecting chromosomal abnormalities, but it's not relevant during the initial visit without understanding the client's medical history.
Correct Answer is B
Explanation
Choice A rationale
Possible signs of pregnancy include symptoms like nausea, but feeling the baby move is not one of them.
Choice B rationale
Feeling fetal movements felt by both the mother and examiner is a positive sign of pregnancy as it confirms fetal presence.
Choice C rationale
Presumptive signs of pregnancy are symptoms felt by the woman, such as missed periods, but not confirmed fetal movements.
Choice D rationale
Probable signs include changes observed by an examiner, like a positive pregnancy test, but not confirmed fetal movements.
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