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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.
B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.
C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.
D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.
Correct Answer is C
Explanation
A. Tying the gown with the gloves on is incorrect. The correct order of donning personal protective equipment (PPE. is to apply the gown first, followed by gloves. Tying the gown after the gloves may compromise proper gown coverage.
B. Tucking the glove cuffs under the gown sleeves is incorrect. The glove cuffs should be pulled over the gown sleeves to ensure a secure, closed barrier between the gown and gloves, helping to prevent contamination.
C. Applying the gown before the gloves is correct. According to infection control guidelines, the gown should be worn first, followed by gloves. This technique ensures that the gown covers the sleeves properly and that the gloves are overlapping the gown cuffs, reducing the risk of contamination.
D. Pushing the gown sleeves up to the elbows is incorrect. Gown sleeves should remain down to cover the wrists to protect the forearms from contamination, especially when caring for a patient with Clostridium difficile, which requires contact precautions.
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