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","C","D","E"]
Explanation
Choice A rationale: Cephalopelvic disproportion is a condition where the baby's head is too large or the mother's pelvis is too small for a vaginal delivery. Amniocentesis does not provide information about this condition.
Choice B rationale: Amniocentesis can be used to detect neural tube defects such as spina bifida and anencephaly.
Choice C rationale: Rh incompatibility occurs when the mother is Rh-negative, and the fetus is Rh-positive. This can lead to hemolytic disease of the newborn (HDN) if untreated. While Rh incompatibility can be detected through blood tests (maternal blood), amniocentesis is typically not used to diagnose this condition.
Choice D rationale: Amniocentesis can be used to determine the fetal gender by analyzing the DNA in the amniotic fluid. This is not the primary purpose of amniocentesis, but it can certainly identify the gender, especially in cases where this information is needed for medical reasons, such as gender-linked genetic disorders.
Choice E rationale: Amniocentesis is commonly used to screen for chromosomal abnormalities such as Down syndrome (trisomy 21) and other genetic conditions.
Correct Answer is B
Explanation
Choice A rationale: Placing the infant in the prone position (face down) after feeding is not recommended for a baby with gastroesophageal reflux. The prone position can increase the risk of aspiration if reflux occurs while the baby is lying down.
Choice B rationale: For an infant with gastroesophageal reflux, placing the baby in an upright position after feeding can help prevent or reduce reflux episodes. Keeping the infant in an upright position allows gravity to assist in keeping stomach contents down and reduces the likelihood of reflux into the esophagus.
Choice C rationale: Placing the infant on the right side after feeding is also not recommended for managing gastroesophageal reflux. The right side position may not be as effective in preventing reflux as the upright position.
Choice D rationale: Placing the baby on either side after feeding is also not recommended for managing gastroesophageal reflux. The upright position is more effective in preventing reflux episodes and promoting digestion. Side-lying positions after feeding may not provide the same benefits and can potentially increase the risk of reflux.
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