A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

Immediately report the situation to the client's provider and prepare the client for induction of labor.

Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.

Turn the client onto her left side.

Offer the client a snack of orange juice and crackers

Answer and Explanation

The Correct Answer is D

A. Immediately report the situation to the client's provider and prepare the client for induction of labor. This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.

B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.

C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.

D. Offer the client a snack of orange juice and crackers. This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.

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Correct Answer is B

Explanation

A) "Maybe next time you can have a vaginal delivery.": This response may not be appropriate as it assumes a future pregnancy and vaginal delivery is guaranteed. It may not address the client's current feelings of disappointment adequately.
B) "It sounds like you are feeling sad that things didn't go as planned.": This is the correct answer as it shows empathy and validates the client's feelings of disappointment. It acknowledges the client's emotions and provides support during this sensitive time.

C) "You can resume sexual relations sooner than if you had delivered vaginally.": While this statement may be true, it is not directly related to the client's expressed feelings of disappointment.
D) "At least you know you have a healthy baby.": This response dismisses the client's feelings and may not be wellreceived, as the client is expressing a desire for emotional support rather
than a reassurance about the baby's health.

A. All of the clients B. A client who has a history of preterm labor C. A client who has mitral valve prolapse D. A client who has been exposed to AIDS

Correct Answer is A

Explanation

A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.

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A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alphafetoprotein (MSAFP) screening for which of the following clients?

Correct Answer is A

Explanation

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