A nurse is preparing to collect a specimen for newborn screening.
Which of the following actions should the nurse take?

Choice A rationale

There is no need to fast before a nonstress test. The test measures the fetal heart rate in response to fetal movements and does not require any dietary restrictions.

Choice B rationale

During a nonstress test, the client will press a button whenever they feel the baby move. This helps correlate fetal movements with heart rate changes.

Choice C rationale

The client is not required to lie flat on their back for the duration of the test. They can be in a semi-reclined position to ensure comfort and avoid supine hypotensive syndrome.

Choice D rationale

Medication to stimulate contractions is not used during a nonstress test. This is done during a contraction stress test, which is a different procedure.

1. Perform a Nitrazine test:Anticipated. This test helps confirm if the membranes have ruptured, which is consistent with the client’s report of fluid leakage.
2. Ensure the client maintains a supine position:Contraindicated. Prolonged supine positioning can reduce blood flow to the fetus and cause maternal hypotension. It’s better to encourage side-lying positions.
3. Prepare the client for catheterization:Nonessential. The client is able to void on her own, so catheterization isn’t necessary at this point.
4. Check client’s temperature every hour:Anticipated. Regular temperature checks are important to monitor for signs of infection, especially after membrane rupture.
5. Encourage frequent ambulation:Anticipated. Ambulation can help progress labor and is generally encouraged if there are no contraindications.
6. Obtain CBC blood sample:Anticipated. A CBC can provide important information about the client’s overall health and detect any potential issues like infection or anemia.
7. Check FHR every 30 min:Anticipated. Regular monitoring of the fetal heart rate is crucial to ensure the well-being of the fetus during labor.