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.
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Correct Answer is D
Explanation
Choice A rationale:
Vaginal hematoma is not a common complication in the 4th stage of labor. This stage primarily involves the recovery and stabilization of the mother after delivery.
Choice B rationale:
Hypoglycemia is not a typical complication in the 4th stage of labor. While blood glucose levels might be monitored during labor, the risk of hypoglycemia is generally higher in neonates, especially if the mother has diabetes.
Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, typically diagnosed during labor or shortly after delivery. It is not specific to the 4th stage of labor.
Choice D rationale:
Uterine hemorrhage is the most significant concern during the 4th stage of labor, also known as the "postpartum”. or "recovery”. stage. It refers to excessive bleeding from the site where the placenta detached. This bleeding can be life-threatening if not managed promptly.
Choice E rationale:
Dehiscence is the separation of surgical incisions, which is not a common complication during the 4th stage of labor.
Correct Answer is B
Explanation
The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.
Choice A rationale:
Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.
Choice B rationale:
Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.
Choice D rationale:
While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.
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