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 B

Explanation

A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.

B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.

C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.

D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.

A. Count the client's respirations for 15 seconds. B. Place the client in a supine position. C. Inform the client when beginning to observe his respirations. D. Observe the movements of the client's chest wall.

Correct Answer is D

Explanation

A. "Count the client's respirations for 15 seconds" is incorrect. The nurse should count respirations for a full 60 seconds to ensure accuracy, especially in postoperative clients, as irregularities may be more easily detected with a longer observation period.

B. "Place the client in a supine position" is not necessary. While the position of the client can affect respiration, the nurse does not need to place the client in a supine position specifically to assess respirations. The client should be in a comfortable position that allows for adequate observation.

C. "Inform the client when beginning to observe his respirations" is incorrect. The client should not be aware that their respirations are being counted, as awareness can alter their breathing patterns and lead to inaccurate data.

D. "Observe the movements of the client's chest wall" is correct. Observing the chest wall allows the nurse to assess the rate, depth, and rhythm of respirations, as well as any signs of distress or abnormal patterns, which is crucial for monitoring postoperative respiratory status.

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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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