A nurse is assisting with the care of a client who is 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

Assist the client into a supine position.

Explain that nonreactivity might require immediate medication administration.

Remind the client to press the button when she feels fetal movement.

Tell the client the test should take about 10 min.

Answer and Explanation

The Correct Answer is C

A. Assist the client into a supine position is incorrect. A supine position can reduce uterine blood flow and may lead to hypotension. The nurse should assist the client into a left-lateral position for optimal results during a nonstress test.

B. Explain that nonreactivity might require immediate medication administration is incorrect. Nonreactivity can indicate fetal distress, but it does not necessarily require medication immediately. Further testing or evaluation would be needed first.

C. Remind the client to press the button when she feels fetal movement is correct. The purpose of the nonstress test is to monitor fetal heart rate acceleration in response to movement. The client is typically instructed to press a button when she feels fetal movement so the nurse can correlate it with fetal heart rate patterns.

D. Tell the client the test should take about 10 min is incorrect. The nonstress test typically takes 20–40 minutes, depending on fetal activity and the need for monitoring.

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Correct Answer is A

Explanation

A. "You should not palpate your child's abdomen prior to surgery." is correct. Palpating the abdomen of a child with Wilms' tumor should be avoided, as this could cause the tumor to rupture and spread cancerous cells. The tumor is typically confined to one kidney and must be surgically removed.

B. "Your child should have surgery in 7 to 10 days to remove the tumor." is incorrect. Surgery to remove a Wilms' tumor typically occurs within 24 to 48 hours after diagnosis, not within 7 to 10 days.

C. "You should give your child captopril 200 mg PO daily." is incorrect. Captopril is not a standard medication used in the treatment of Wilms' tumor. Treatment often involves surgery, chemotherapy, and sometimes radiation therapy.

D. "Your child will not require further treatment after removal of the tumor." is incorrect. Post-surgical treatment, such as chemotherapy and/or radiation therapy, is often required, depending on the stage and extent of the tumor.

A. Administer an anti-anxiety medication. B. Minimize environmental stimuli in the client's surroundings. C. Explore behaviors that have helped to reduce the client's anxiety in the past. D. Explain to the client that anxiety causes physical manifestations.

Correct Answer is B

Explanation

A. Administer an anti-anxiety medication is not the first action. The nurse should first assess and manage the client's environment and emotional state before resorting to medication.

B. Minimize environmental stimuli in the client's surroundings is correct. The client is experiencing anxiety, and minimizing stimuli helps to reduce environmental triggers and can immediately alleviate distress.

C. Explore behaviors that have helped to reduce the client's anxiety in the past is a good intervention but should not be the first response. The immediate priority is to reduce the anxiety by controlling the environment.

D. Explain to the client that anxiety causes physical manifestations is helpful but should occur after the immediate anxiety-reduction measures are in place. Providing this information can be part of the therapeutic process but does not address the client’s immediate distress.

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A nurse is assisting with the care of a client who is 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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