A nurse is caring for a client who is at 34 weeks of gestation and is preparing to undergo a nonstress test. Which of the following actions should the nurse take?

Instruct the client that oxytocin is administered during the procedure.

Inform the client that this procedure assists in indicating Down syndrome.

Assist the client to a lateral tilt position prior to the procedure.

Ensure the client has been NPO for 6 hr prior to the procedure.

Answer and Explanation

The Correct Answer is C

A) Incorrect- Oxytocin is not typically administered during a nonstress test.

B)   Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C)   Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D)   Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.

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Correct Answer is C

Explanation

A) Incorrect- Taking the medication with breakfast may not ensure optimal absorption of iron, especially if the breakfast does not include a vitamin C source.
B) Incorrect- Taking the medication with the midday meal is not the best option for enhancing iron absorption.
C) Correct - Taking the medication with a glass of orange juice provides a source of vitamin C, which can improve iron absorption.
D) Incorrect- Taking the medication with milk is not recommended, as calcium in milk can interfere with iron absorption.

A. Insert the needle at a 45° angle B. Obtain parental consent C. Give the first dose at 24 hr after birth. D. Administer the medication into the dorsal gluteal muscle

Correct Answer is C

Explanation

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

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A nurse is caring for a client who is at 34 weeks of gestation and is preparing to undergo a nonstress test. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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