A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test. Which of the following statements should the nurse make?

"You will not be able to eat or drink anything for 8 hours prior to the test."

"You will be required to lie flat on your back for the duration of the test

"You will receive medication through an IV line to stimulate contractions."

"You will press the provided button when you feel the baby moving during the test.

Answer and Explanation

The Correct Answer is D

(a) "You will not be able to eat or drink anything for 8 hours prior to the test."
There are no fasting requirements for a nonstress test. The client can eat and drink normally before the test. Nonstress tests do not require the same preparation as some other medical tests, such as fasting or dietary restrictions.

(b) "You will be required to lie flat on your back for the duration of the test."
Lying flat on the back can cause supine hypotension syndrome in pregnant women, which can lead to decreased blood flow to the fetus. Instead, clients are typically positioned in a semi-Fowler's or lateral position to avoid this issue.

(c) "You will receive medication through an IV line to stimulate contractions."
This describes a contraction stress test, not a nonstress test. A nonstress test involves monitoring the fetal heart rate in response to natural fetal movements without inducing contractions through medication.

(d) "You will press the provided button when you feel the baby moving during the test."
During a nonstress test, the client is instructed to press a button whenever they feel fetal movement. This helps the healthcare provider correlate fetal movements with changes in the fetal heart rate, which can indicate fetal well-being.

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Correct Answer is C

Explanation

(A) Maternal temperature 36.3°C (101°F):
While maternal temperature elevation can indicate infection, in this scenario, the sudden gush of vaginal fluid takes precedence as it could be indicative of premature rupture of membranes. However, assessing maternal temperature is important for ruling out maternal infection, but it is not the priority manifestation compared to assessing fetal well-being.

(B) Amniotic fluid with meconium noted:
While the presence of meconium in the amniotic fluid is concerning, assessing fetal heart tones is the priority. Meconium-stained amniotic fluid can indicate fetal distress, but the immediate concern is to determine if the fetus is experiencing any compromise or distress by assessing the fetal heart rate.

(C) Fetal heart tones 98/min:
In this scenario, the priority is to assess the well-being of the fetus. Fetal heart tones provide critical information about fetal status, indicating whether the baby is experiencing any distress or compromise. A fetal heart rate of 98 beats per minute (bpm) is within the normal range for a fetus at 34 weeks of gestation. However, any abnormalities or significant deviations from the normal fetal heart rate range may indicate fetal distress, requiring immediate intervention.

(D) Foul-smelling vaginal discharge:
Foul-smelling vaginal discharge can indicate infection, such as chorioamnionitis, which is a concern during pregnancy. However, in this scenario, assessing fetal well-being takes precedence as it is essential to ensure timely interventions to assess and manage any fetal distress.

A. Weigh the newborn's wet diaper. B. Determine the newborn's respiratory rate. C. Auscultate the newborn's bowel sounds. D. Swaddle the newborn in blankets.

Correct Answer is B

Explanation

Answer: B. Determine the newborn's respiratory rate.

Rationale:

A. Weigh the newborn's wet diaper:
While monitoring fluid output is important in assessing hydration status and overall health, it is not the immediate priority. In the context of a newborn with neonatal abstinence syndrome (NAS), the respiratory status takes precedence, especially given that withdrawal can affect respiratory function.

B. Determine the newborn's respiratory rate:
Assessing the respiratory rate is crucial, as newborns with NAS may experience respiratory distress, including increased respiratory effort or apnea. Identifying any respiratory issues early allows for prompt intervention, which is vital for the newborn's safety and well-being. Ensuring adequate respiratory function is a priority in this population.

C. Auscultate the newborn's bowel sounds:
While assessing bowel sounds is relevant to monitoring gastrointestinal function and potential withdrawal symptoms, it is not the immediate priority. Changes in bowel sounds may occur due to the syndrome, but respiratory assessment should come first to ensure stability.

D. Swaddle the newborn in blankets:
Swaddling can provide comfort to a newborn with NAS; however, it is not the first action to take. Comfort measures are important, but they should follow critical assessments of the newborn's respiratory and overall clinical status to ensure safety.

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A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

Rationale:

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