A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

Choice A rationale:

The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.

Choice B rationale:

The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.

Choice C rationale:

This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.

Choice D rationale:

The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.

Choice A rationale:

The nurse does not need to report the blood pressure finding. While blood pressure is an essential vital sign to monitor during pregnancy, the scenario does not indicate any abnormalities or concerning values in the client's blood pressure. Therefore, there is no immediate cause for reporting this finding.

Choice B rationale:

The nurse should report cerebral manifestations to the provider. The client's complaint of a more severe headache, rated at 5 on a 0 to 10 pain scale, along with feeling dizzy when getting up from the examination table, may indicate potential neurological symptoms. These could be signs of conditions like preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, including the brain.

Choice C rationale:

The nurse should also report fetal heart rate findings to the provider. The client reports occasional contractions and positive fetal movement, but there is no mention of fetal heart rate in the nurse's notes. Monitoring the fetal heart rate is crucial during prenatal care, as changes in fetal heart rate could indicate fetal distress or other complications.

Choice D rationale:

The nurse does not need to report respiratory rate findings. There is no indication in the nurse's notes of any respiratory issues or complaints from the client, making this finding less relevant to the current situation.

Choice E rationale:

The nurse does not need to report deep tendon reflexes in this context. Deep tendon reflexes are not typically a priority assessment during routine prenatal care unless there are specific concerns or indications of neurological issues.

Choice F rationale:

The nurse does not need to report gastrointestinal assessment findings based on the information provided in the scenario. While the client reports "heartburn,”. there are no other gastrointestinal symptoms or indications of acute gastrointestinal issues requiring immediate reporting.