A nurse is reinforcing teaching with a client who is at weeks of gestation and scheduled for a non-stress 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

I have to lie on my back during the test

The baby’s heart rate will be monitored during the test

I will be able to go to the bathroom during the test if necessary

Answer and Explanation

The Correct Answer is B

Rationale for Choice A:
It is accurate that scheduling the NST when the baby is usually active is beneficial. This is because fetal movement is expected to cause accelerations in the fetal heart rate, which is a positive sign of fetal well-being.
By scheduling the test during a time of typical fetal activity, the chances of obtaining a reactive NST (a normal result) are increased.
Therefore, this statement does not indicate a need for further teaching.

Rationale for Choice B:
Lying on the back during the NST is not recommended.
This position can cause the weight of the uterus to compress the major blood vessels (the inferior vena cava and aorta), potentially reducing blood flow to the placenta and fetus.
Reduced blood flow can, in turn, lead to a decrease in fetal heart rate and movement.
To avoid this, the recommended position for NST is a semi-Fowler's position, which involves being partially reclined with the head and upper body elevated.
This position helps to promote uterine perfusion and prevent supine hypotension.

Rationale for Choice C:
It is accurate that the baby's heart rate will be monitored during the NST.
This is the primary purpose of the test: to assess the fetal heart rate response to fetal movement. Therefore, this statement does not indicate a need for further teaching.

Rationale for Choice D:
It is accurate that the client will be able to go to the bathroom during the NST if necessary. The test is noninvasive and does not require strict immobility.
The client can move around and use the bathroom as needed, as long as the fetal heart rate monitor is not disconnected.
Therefore, this statement does not indicate a need for further teaching.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.

Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.

Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.

Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.

A. At the umbilicus. B. 3 cm above the umbilicus. C. 3 cm below the umbilicus. D. 5 cm above the umbilicus.

Correct Answer is B

Explanation

Choice A:
The umbilicus is typically the location of the fundus at around 20 weeks of gestation, not 22 weeks.
If the fundus is at the umbilicus at 22 weeks, it could indicate that the fetus is not growing at the expected rate. This would warrant further investigation, such as an ultrasound, to assess fetal growth and development.

Choice C:
3 cm below the umbilicus is too low for a 22-week gestation.
This would suggest that the fetus is smaller than expected for the gestational age.
Possible causes of this include incorrect dating of the pregnancy, fetal growth restriction, or oligohydramnios (low amniotic fluid).

Choice D:
5 cm above the umbilicus is too high for a 22-week gestation.
This could indicate that the woman is carrying multiples, has polyhydramnios (excess amniotic fluid), or that the fetus is larger than expected for the gestational age (macrosomia).
Importance of Fundal Height Measurement:
Fundal height measurement is a simple, non-invasive way to assess fetal growth and development during pregnancy. It is typically measured at each prenatal appointment, starting at around 20 weeks of gestation.
By tracking the fundal height over time, healthcare providers can identify potential problems with fetal growth and make necessary interventions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reinforcing teaching with a client who is at weeks of gestation and scheduled for a non-stress test (NST). Which of the following statements by the client indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

A nurse is preparing to palpate the uterine fundus of a client who is at 22 weeks of gestation to measure fundal height. At which of the following locations should the nurse expect to find the fundus?

Correct Answer is B

Explanation

A nurse is collecting data from a client who requests a prescription for a diaphragm. Which of the following findings should the nurse identify as a contraindication to the client’s use of a diaphragm?

A nurse is reinforcing nutrition teaching with a client during the first prenatal visit. Which of the following statements by the client indicates understanding of the teaching?

A nurse in a prenatal office is caring for a client who is at gestation and is scheduled for an amniocentesis. The client asks why ultrasounds are performed prior to the procedure. Which of the following responses by the nurse is appropriate?

A nurse is assisting with the care of a client who is in active labor at 9 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following responses by the nurse is appropriate?

A nurse is assisting with a community program to educate adolescents about contraception. After the class, a 15-year-old girl asks the nurse which method is best for her to use. Which of the following statements is an appropriate nursing response?

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives?

A nurse is reinforcing teaching with a client who is pregnant and has a new prescription for ferrous sulfate due to iron deficiency anemia. The nurse should instruct the client to take this medication with which of the following?