A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?
Kleihauer-Betke test
Amnioinfusion
Administration of terbutaline
Contraction stress test
The Correct Answer is D
A. Kleihauer-Betke test. This test is used to detect fetal-maternal hemorrhage by identifying fetal red blood cells in maternal circulation. It is not related to a nonreactive NST, which indicates the need for further fetal well-being assessment rather than checking for fetal-maternal bleeding.
B. Amnioinfusion. This procedure involves infusing fluid into the amniotic sac to relieve umbilical cord compression or dilute meconium-stained amniotic fluid. It is not an appropriate intervention for a nonreactive NST, as it does not assess fetal oxygenation or reactivity.
C. Administration of terbutaline. Terbutaline is a tocolytic used to relax the uterus and prevent preterm labor. It is not indicated for a nonreactive NST, as the concern in this scenario is fetal well-being rather than uterine activity.
D. Contraction stress test. A nonreactive NST means that the fetal heart rate does not demonstrate adequate accelerations, which can indicate potential fetal hypoxia. A contraction stress test is performed next to evaluate how the fetal heart rate responds to contractions, helping determine if the fetus can tolerate labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer aspirin for pain. Aspirin is an antiplatelet medication and is not appropriate for managing pain in a client with deep vein thrombosis (DVT). Additionally, aspirin can increase the risk of bleeding, especially in clients receiving anticoagulant therapy, so it should be avoided in this context.
B. Apply an ice pack to the affected extremity for 20 min every 2 hr. While ice packs may be helpful in reducing swelling, applying ice is generally not recommended for DVT because it may cause vasoconstriction and increase the risk of thrombosis. It’s more important to follow appropriate medical treatment guidelines for DVT management.
C. Massage the affected extremity every 4 hr. Massaging the affected extremity is contraindicated in cases of DVT, as it can dislodge the thrombus, potentially leading to a pulmonary embolism or other serious complications.
D. Initiate bed rest. Initiating bed rest is the appropriate action for a client with DVT. Bed rest helps prevent further clot formation and reduces the risk of complications. The healthcare provider will also typically order anticoagulant therapy to manage the condition safely. The client should avoid movement of the affected leg until medically advised otherwise.
Correct Answer is ["A","B"]
Explanation
A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.
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