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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B:
Implantation typically occurs 6 to 12 days after ovulation, not 2 to 3 weeks. This is a crucial distinction because it aligns with the developmental timeline of the early embryo and the physiological changes in the endometrium that prepare for implantation.
The timing of implantation is essential for establishing a viable pregnancy. If implantation occurs too early or too late, it can lead to complications such as early pregnancy loss or ectopic pregnancy.
Understanding the correct timing of implantation is vital for healthcare professionals to provide accurate information and guidance to clients regarding conception and early pregnancy.
Choice A:
Sperm can indeed remain viable in the woman's reproductive tract for up to 5 days. This means that intercourse that occurs several days before ovulation can still lead to conception.
The lifespan of sperm is important for understanding fertility and timing intercourse for those trying to conceive.
Choice C:
Fertilization does typically occur in the outer third of the fallopian tube, also known as the ampulla. This is where the sperm meets the egg, and fertilization takes place.
The location of fertilization is significant because it ensures that the fertilized egg, or zygote, has time to travel down the fallopian tube and implant in the uterus.
Choice D:
Bleeding can sometimes accompany implantation, known as implantation bleeding. This bleeding is usually light and occurs around the time of expected menstruation.
It is important to be aware of implantation bleeding as it can sometimes be mistaken for a menstrual period.
Correct Answer is D
Explanation
Rationale for Choice A:
Judgmental and shaming: The statement "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?" conveys judgment and may make the adolescent feel ashamed or embarrassed. This can create a barrier to open communication and discourage the teen from seeking further guidance.
Dismisses the teen's concerns: It does not directly address the teen's question about contraception, suggesting that her concerns are not valid or important.
Does not provide helpful information: It does not offer any guidance or education about contraception, leaving the teen without the information she needs to make informed decisions about her sexual health.
Rationale for Choice B:
Erects barriers to access: Requiring parental consent for an examination can delay or prevent the teen from obtaining contraception, even if she is legally allowed to do so without parental consent.
Discourages open communication: It may make the teen feel like she cannot trust the nurse or that her privacy will not be respected, leading her to withhold information or avoid seeking further help.
Rationale for Choice C:
Defers responsibility: It shifts the responsibility for providing contraception counseling to the doctor, potentially delaying the teen's access to information and services.
May not be necessary: A physical examination is not always required before prescribing contraception, and in some cases, a nurse practitioner or other qualified health professional can provide this service.
Rationale for Choice D:
Open and non-judgmental: It invites the teen to share information about her sexual activity without judgment or pressure. Gathers essential information: It allows the nurse to assess the teen's individual needs and preferences, which is crucial for recommending the most appropriate contraceptive method.
Promotes informed decision-making: It empowers the teen to make informed choices about her sexual health by providing her with accurate and comprehensive information about contraception.
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