A nurse is caring for a client who is pregnant and undergoing a nonstress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take?
Turn the client onto her left side.
Encourage the client to walk around and then resume monitoring.
Apply vibroacoustic stimulation to the woman's abdomen.
Report the findings to the provider and prepare the client for induction of labor.
The Correct Answer is C
Choice A rationale:
Turning the client onto her left side is a common measure to improve fetal oxygenation and is often used during labor. However, in this scenario, the nurse needs to address the absence of fetal movement during the nonstress test.
Choice B rationale:
Encouraging the client to walk around and then resume monitoring is not appropriate when there is a concern about the absence of fetal movement during the nonstress test.
Choice C rationale:
Vibroacoustic stimulation involves using sound stimulation to elicit fetal movement. If there has been no fetal movement during the nonstress test, this intervention can be used to assess fetal well-being and provoke a response from the fetus.
Choice D rationale:
Preparing the client for induction of labor is not indicated based solely on the absence of fetal movement during a nonstress test. Further assessment and interventions are needed before considering induction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Maternal gestational diabetes can lead to the newborn being larger than average (macrosomia) due to the impact of high blood sugar levels in the mother affecting fetal growth.
Choice B rationale:
Newborn hypoglycemia isa common complication of maternal gestational diabetes due to the elevated insulin levels in the newborn at birth
Choice C rationale:
Oligohydramnios refers to decreased amniotic fluid, which can be a complication of various factors, but it is not directly related to maternal gestational diabetes.
Choice D rationale:
Placenta previa is a condition where the placenta partially or completely covers the cervix, which is unrelated to maternal gestational diabetes.
Correct Answer is C
Explanation
Choice A rationale: While colostrum is present in the first few days after delivery, it takes a few more days for breast milk to "come in" and increase in volume.
Choice B rationale: Waiting for 6 to 8 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
Choice C rationale: Colostrum, the first milk, is typically produced in small amounts during the first few days after delivery. Breast milk usually "comes in" or increases in volume around 3 to 5 days after childbirth. This transition from colostrum to mature milk is normal and expected.
Choice D rationale: Waiting for 10 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
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