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","E"]
Explanation
Choice A rationale: Keeping the newborn in the center of a large crib is not a specific calming strategy and may not offer the comfort and security that the baby needs.
Choice B rationale: Taking the newborn for a ride in the car can be a calming strategy for some babies. The gentle motion and humming sound of the car can help soothe the baby.
Choice C rationale: Carrying the newborn in a front or backpack can provide comfort and security to the baby. The closeness to the parent's body and the rhythmic movement can help calm the baby.
Choice D rationale: Allowing the newborn to continue crying until she falls asleep is not a recommended strategy. Responding to the baby's cries and providing comfort and soothing is essential for the baby's emotional well-being.
Choice E rationale: Swaddling the newborn in a receiving blanket can help mimic the feeling of being in the womb, providing comfort and security to the baby. It can also prevent the startle reflex and promote better sleep.
Correct Answer is B
Explanation
A. SGA newborns often have increased circulating RBCs (polycythemia) due to chronic hypoxia in utero, not decreased RBCs.
B. Blood glucose instability (hypoglycemia) is common in SGA newborns due to decreased glycogen stores and increased metabolic demands.
C. Retinopathy of prematurity is more commonly associated with preterm infants and prolonged oxygen therapy rather than SGA status.
D. SGA newborns typically have a scaphoid (sunken) rather than a well-rounded abdomen due to decreased subcutaneous fat stores.
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