A nurse is caring for a client who is having a nonstress test.
The fetal heart rate (FHR) baseline is 130 bpm, there is moderate variability, but there have been no accelerations or fetal movement.
Which of the following actions should the nurse complete next?
Encourage the client to walk around for 30 minutes, then resume monitoring.
Perform vibroacoustic stimulation.
Immediately report the situation to the provider and prepare the client for induction of labor.
Reposition the client into a supine position.
The Correct Answer is B
Choice A rationale
Encouraging the client to walk around for 30 minutes and then resume monitoring is not the most appropriate action in this scenario. Walking may help stimulate fetal movement, but it is not the first-line intervention when there are no accelerations or fetal movement during a nonstress test. The nurse should try other methods to stimulate fetal movement before resorting to walking.
Choice B rationale
Performing vibroacoustic stimulation is the correct action. Vibroacoustic stimulation involves using a device to produce a sound and vibration near the maternal abdomen to stimulate fetal movement and heart rate accelerations. This method is non-invasive and can help determine fetal well-being by eliciting a response from the fetus.
Choice C rationale
Immediately reporting the situation to the provider and preparing the client for induction of labor is premature. The absence of accelerations or fetal movement during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions, such as vibroacoustic stimulation, should be attempted first.
Choice D rationale
Repositioning the client into a supine position is not recommended. The supine position can lead to supine hypotensive syndrome, which can decrease blood flow to the fetus. The nurse should avoid placing the client in a supine position and instead try other methods to stimulate fetal movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A non-stress test (NST) is a common initial assessment for decreased fetal movement. It evaluates fetal heart rate patterns in response to fetal movements, providing information about fetal well-being and oxygenation.
Choice B rationale
A biophysical profile (BPP) is a more comprehensive assessment that includes an NST and ultrasound evaluation of fetal movements, tone, breathing, and amniotic fluid volume. It may be ordered if the NST results are non-reassuring or if there are other concerns.
Choice C rationale
An ultrasound can provide valuable information about fetal growth, amniotic fluid volume, and placental function. It may be used in conjunction with other tests but is not the first-line assessment for decreased fetal movement.
Choice D rationale
Amniocentesis is an invasive procedure used for specific indications, such as genetic testing or assessing fetal lung maturity. It is not typically used for initial assessment of decreased fetal movement.
Correct Answer is D
Explanation
A. Chest physiotherapy can help mobilize secretions, but it primarily aids in clearing secretions rather than directly thinning them. While it may be beneficial as part of a comprehensive approach, it is not the most direct method for thinning secretions.
B. Prelubricating the suction catheter with saline does not effectively thin secretions. In fact, using saline in this way may introduce moisture that could inadvertently lead to complications, such as introducing infection or causing the client to cough.
C. While hyperventilation and providing oxygen are important for maintaining oxygen saturation during suctioning, this method does not help in thinning secretions. It may be used to ensure oxygenation during suctioning but is not effective for secretion management.
D. Providing humidified oxygen is an effective way to thin secretions. Humidity adds moisture to the airways, which can help to keep secretions less viscous and easier to clear. This is a standard practice in managing secretions in clients with tracheostomies.
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