A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?
"This monitor gives me information related to fetal heart rate fluctuations during your labor."
"This monitor measures the intensity and frequency of your contractions so I can observe labor progress."
"This monitor allows me to observe your labor progress. By observing the pattern, I can tell how strong your contractions are."
"This monitor provides me with information related to the duration and frequency of your contractions."
The Correct Answer is D
A. "This monitor gives me information related to fetal heart rate fluctuations during your labor." – Incorrect; the TOCO does not monitor fetal heart rate; the fetal heart rate is detected using a Doppler or fetal scalp electrode.
B. "This monitor measures the intensity and frequency of your contractions so I can observe labor progress." – Incorrect; the TOCO can measure frequency and duration, but not intensity (which requires an intrauterine pressure catheter).
C. "This monitor allows me to observe your labor progress. By observing the pattern, I can tell how strong your contractions are." – Incorrect; TOCO does not measure contraction strength, only duration and frequency.
D. "This monitor provides me with information related to the duration and frequency of your contractions." – Correct; a TOCO detects and records contraction frequency and duration, but not intensity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Body weight – Correct; the best indicator of fluid loss in infants is a change in weight because infants have higher water content and small changes can significantly impact hydration status.
B. Blood pressure – Incorrect; infants can maintain blood pressure until dehydration becomes severe.
C. Respiratory rate – Incorrect; respiratory rate may increase with dehydration but is not the most reliable indicator.
D. Skin integrity – Incorrect; poor skin turgor is a sign of dehydration, but weight loss is more objective and accurate.
Correct Answer is D
Explanation
A. Encourage the client to nurse more frequently so her milk will come in. – Incorrect; milk production typically begins between days 2-5 postpartum, not 14 hours postpartum.
B. Report the client's temperature elevation. – Incorrect; a temperature of 37.7°C (100°F) is within normal postpartum range due to dehydration and hormonal shifts.
C. Increase IV fluids. – Incorrect; IV fluids are not needed unless dehydration is suspected.
D. Ask the client to empty her bladder. – Correct; a fundus deviated to the right suggests a full bladder, which can impede uterine involution and increase postpartum hemorrhage risk.
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