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A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

"You will receive a medication through an IV for this test.”

"You should expect the test to take about 30 minutes.”

"You should not eat or drink for 4 hours prior to the test.”

"This test will help determine if your baby's lungs are mature.”

Answer and Explanation

The Correct Answer is B

Choice A rationale:

This statement is incorrect. A nonstress test does not involve receiving medication through an

IV. It is a simple and non-invasive test that monitors the baby's heart rate in response to its movements.

Choice B rationale:

This is the correct choice. A nonstress test typically takes about 30 minutes to complete. During the test, the client will have a fetal heart rate monitor placed on her abdomen to measure the baby's heart rate while it is moving.

Choice C rationale:

This statement is incorrect. There is no requirement for the client to fast or restrict food and drink before a nonstress test. The client can eat and drink as usual before the procedure.

Choice D rationale:

This statement is incorrect. A nonstress test is not used to determine if the baby's lungs are mature. Instead, it assesses the baby's heart rate patterns in response to its own movements, which helps evaluate the baby's overall well-being in the third trimester of pregnancy.

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Correct Answer is C

Explanation

Choice A rationale:

Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has

been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)

Choice B rationale:

This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.

Choice C rationale:

This is the correct choice, as explained above. Choice D rationale:

This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.

A. Assist the client to void every 3 hr. B. Monitor contractions every 30 min. C. Place the client into a lithotomy position. D. Encourage the client to use a pant-blow breathing pattern.

Correct Answer is D

Explanation

Choice D rationale:

During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.

Choice A rationale:

Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.

Choice B rationale:

Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.

Choice C rationale:

Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.

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A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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