A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Maintain the client NPO throughout the procedure.
Place the client in a supine position,
Instruct the client to massage the abdomen to stimulate fetal movement
Instruct the client to press the provided button each time fetal movement is detected
The Correct Answer is D
The correct answer is D.
A. Maintain the client NPO throughout the procedure: It is not necessary to maintain the client NPO (nothing by mouth) for a nonstress test. The test primarily involves monitoring fetal heart rate in response to the baby's movements and does not require fasting.
B. Place the client in a supine position: Placing the client in a left lateral position is often preferred for NST to optimize uterine blood flow and fetal oxygenation. The supine position can compromise blood flow to the uterus and is generally avoided, especially in later pregnancy.
C. Instruct the client to massage the abdomen to stimulate fetal movement: While the goal of the NST is to monitor fetal movements, instructing the client to actively stimulate fetal movement through abdominal massage is not a standard part of the procedure. Fetal movements should occur naturally.
D. Instruct the client to press the provided button each time fetal movement is detected: This is the correct action. During a nonstress test, the client is typically provided with a button to press whenever she feels fetal movement. This helps correlate fetal movements with changes in the fetal heart rate on the monitor, providing valuable information about the baby's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Turn the client onto her side.
A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.
B. Turning the client onto her side is the correct first action.
Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.
C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.
D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.
Correct Answer is B
Explanation
The correct answer is B. The client will experience a successful induction of labor.
A. The Bishop score is a pre-induction assessment that evaluates several factors, including cervical dilation, effacement, consistency, position, and fetal station. It is used to predict the likelihood of a successful induction of labor. A high Bishop score indicates favorable conditions for induction.
B. Correct. A higher Bishop score indicates a more favorable cervix for induction, and the chances of a successful induction of labor are increased.
C. Lower back pain during labor is not specifically associated with the Bishop score. It can be a common complaint during labor, but it is not predicted by the Bishop score.
D. Dinoprostone is a prostaglandin used for cervical ripening. If the Bishop score indicates an unfavorable cervix, dinoprostone or other cervical ripening agents may be considered to prepare the cervix for induction.
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