A nurse is teaching a client who is scheduled for a non-stress test. Which of the following information should the nurse include? Choice Options:
An IV will be initiated prior to the test.
The client will be asked to stimulate her nipples for 5 minutes during the test.
The client will receive an ultrasound prior to the test.
An external fetal monitor will be used to monitor the fetus.
The Correct Answer is D
Rationale for Choice A:
An IV is not routinely initiated prior to a non-stress test. It may be started if a biophysical profile (BPP), which includes an ultrasound, is also being performed, or if there is a risk of complications that may necessitate immediate intervention. However, it is not a standard part of the non-stress test itself.
Rationale for Choice B:
Nipple stimulation is not a standard component of a non-stress test. It may be used in some cases to try to induce fetal movement if the fetus is not moving actively enough during the test. However, it is not a routine part of the procedure.
Rationale for Choice C:
An ultrasound is not typically performed prior to a non-stress test. It may be done as part of a BPP, but it is not necessary for the non-stress test itself.
Rationale for Choice D:
An external fetal monitor is essential for conducting a non-stress test. This monitor uses two belts that are placed around the mother's abdomen. One belt measures the fetal heart rate, and the other belt measures uterine contractions. The monitor records the fetal heart rate and any contractions for a period of 20 to 40 minutes. The test is considered reactive (normal) if the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice during the test. This acceleration in heart rate is typically in response to fetal movement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Severe nausea and vomiting
While nausea and vomiting can be common in early pregnancy, including ectopic pregnancies, they are not specific indicators of an ectopic pregnancy.
Approximately 70-80% of pregnant women experience nausea and vomiting, regardless of the location of the pregnancy. Hence, the presence of severe nausea and vomiting alone would not definitively point towards an ectopic pregnancy.
Choice B: Uterine enlargement greater than expected for gestational age
In an ectopic pregnancy, the fertilized egg implants outside the uterus, typically in the fallopian tube. This means the uterus would not be expected to enlarge as it would in a normal intrauterine pregnancy. In fact, uterine size might be smaller than expected for gestational age in cases of ectopic pregnancy.
Choice C: Copious vaginal bleeding
While vaginal bleeding can occur in ectopic pregnancies, it's not always present and is not the most common initial symptom. When bleeding does occur, it's often lighter than a normal menstrual period and may be brown or dark in color.
Copious vaginal bleeding is more likely to occur in cases of miscarriage or other pregnancy complications.
Choice D: Pelvic pain
Pelvic pain is the most common and characteristic symptom of an ectopic pregnancy.
The pain is often described as sharp, stabbing, or cramping, and it may be localized to one side of the abdomen. The pain can be intermittent or constant, and it may worsen with activity or movement.
The pain is caused by the stretching of the fallopian tube as the ectopic pregnancy grows. In some cases, the pain can be severe enough to cause nausea and vomiting.
Therefore, pelvic pain is the most reliable finding that the nurse should expect in a client with a possible ectopic pregnancy at 8 weeks of gestation.
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.
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