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

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B.

A. Increased fetal movement: Increased fetal movement is generally not considered a complication after an amniocentesis. Fetal movement is a positive sign, indicating fetal well-being. However, it's important to monitor for any changes in movement patterns.

B. Leakage of fluid from the vagina: Leakage of amniotic fluid from the vagina is a potential complication after amniocentesis. It may indicate rupture of the amniotic sac, which can lead to preterm labor and other complications. This finding should be reported promptly to the healthcare provider.

C. Upper abdominal discomfort: Mild upper abdominal discomfort can occur after an amniocentesis, but it is not typically a severe complication. It may be related to the procedure itself and often resolves with rest. However, persistent or severe discomfort should be reported.

D. Urinary frequency: Urinary frequency is not typically associated with complications after an amniocentesis. It may be a normal symptom related to the position of the uterus or other factors, but it does not generally warrant immediate reporting as a complication.

A. Determine respiratory function. B. Increase the TV fluid rate. C. Access emergency medications from cart D. Collect a maternal blood sample for coagulopathy studies

Correct Answer is A

Explanation

The correct answer is A.

A. Determine respiratory function: The priority is to assess the client's airway, breathing, and circulation (ABCs). If the client becomes unresponsive, the nurse should quickly assess whether the airway is clear, check for breathing, and determine if there is a pulse. This initial assessment is crucial for identifying and addressing any immediate life-threatening issues.

B. Increase the TV fluid rate: While fluid administration may be necessary in certain situations, it is not the first priority when a client becomes unresponsive. Assessing respiratory function and circulation takes precedence to address immediate life-threatening concerns.

C. Access emergency medications from the cart: Accessing emergency medications may be necessary, but it should occur after the initial assessment of the client's airway, breathing, and circulation. Administering medications without first assessing the client's ABCs may delay appropriate interventions.

D. Collect a maternal blood sample for coagulopathy studies: This action is important for assessing coagulation status, but it is not the first priority when a client becomes unresponsive. The immediate focus should be on ensuring the client has a patent airway, is breathing, and has a pulse.

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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?

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Correct Answer is A

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