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 D

Explanation

A. "I will increase my fluid intake to 1,700 milliliters per day.": While maintaining hydration is important for people with COPD, 1,700 milliliters may not be sufficient for all individuals. Fluid intake should be tailored to the patient's needs, and the client should be advised to follow specific guidelines from their provider.

B. "I should do aerobic exercises once per day.": This is somewhat correct, as regular exercise is beneficial for people with COPD, but it should be individualized based on the client's current condition and limitations. However, exercise should not be the primary focus of initial teaching for someone newly diagnosed with COPD.

C. "I will consume low-protein, low-calorie foods.": This is incorrect. COPD clients generally need a balanced diet with sufficient protein and calories to support respiratory function and muscle strength. A low-calorie diet may contribute to weight loss and muscle wasting, which can worsen COPD symptoms.

D. "I should practice pursed-lip breathing exercises.": This is correct. Pursed-lip breathing helps to control shortness of breath, improve ventilation, and reduce the work of breathing, which is an important strategy for individuals with COPD to manage their condition.

A. "My child still wets the bed at least two times per week." B. "I have a difficult time getting my child to eat green vegetables." C. "My child continually asks me the same questions." D. "I have noticed that my child is withdrawn since we switched day care providers."

Correct Answer is D

Explanation

A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.

B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.

C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.

D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.

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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?

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