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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: Eight months is too early to transition to whole milk. At this age, infants still need the complete nutrition provided by breast milk or formula.
Choice B rationale: Ten months is still too early for transitioning to whole milk. Breast milk or formula should be the primary source of nutrition until around 12 months of age.
Choice C rationale: At 6 months of age, infants are usually just starting to introduce solid foods, but breast milk or formula remains the primary source of nutrition. Transitioning to whole milk at this age is not recommended.
Choice D rationale: The American Academy of Pediatrics (AAP) recommends transitioning from breast milk or formula to whole cow's milk at around 12 months of age. Before that age, breast milk or formula provides essential nutrients for the baby's growth and development.

A. "There's absolutely nothing for you to worry about. Newborns often breathe like this." B. "I'll sit here while you feed him and we'll check out his breathing." C. "You are going to be a very good, responsible mother to this baby." D. "All new mothers feel a bit anxious about things like this."

Correct Answer is B

Explanation

Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching to transition from breastfeeding to whole milk with the parents of an infant. Which of the following months of age should the nurse recommend for transitioning the infant to whole milk?

Correct Answer is D

Explanation

A nurse is caring for a client who is 1 day postpartum. The client tells the nurse, "The baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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