A nurse is reinforcing teaching with a client who is at 30 weeks of gestation and scheduled for a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?
"I need to schedule the test when the baby is usually active.".
"The baby's heart rate will be monitored during the test.".
"I will have to lie on my back during the test.".
"I will be able to go to the bathroom during the test as necessary.".
The Correct Answer is C
Choice A rationale:
The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.
Choice B rationale:
The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.
Choice C rationale:
This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.
Choice D rationale:
The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Cover the client with warm blankets.
Choice A rationale:
Shaking chills are not always associated with fever, especially during the immediate postpartum period. While determining the client's temperature can rule out infection, this action does not provide immediate relief or comfort. The chills are often physiological due to hormonal and vascular changes.
Choice B rationale:
Seizure precautions are unnecessary unless additional symptoms, such as loss of consciousness or convulsions, are observed. Shaking chills are typically not indicative of a neurological event but rather a normal postpartum response.
Choice C rationale:
Notifying the charge nurse is unnecessary unless the shaking is accompanied by other abnormal findings, such as fever or prolonged chills. The immediate priority is to ensure client comfort.
Choice D rationale:
Providing warm blankets addresses the primary issue of discomfort caused by postpartum chills. This is a standard intervention to stabilize the client's body temperature and promote comfort. The action is immediate, non-invasive, and effective.
Correct Answer is A
Explanation
Choice A rationale :
The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.
Choice B rationale
Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.
Choice C rationale
Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.
Choice D rationale
Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.
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