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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale:
Large amount of bright red vaginal bleeding is the cardinal sign of placenta previa. This is because the placenta is abnormally positioned low in the uterus, covering the cervix partially or completely. When the cervix starts to dilate in preparation for labor, it can detach from the uterine wall, leading to significant bleeding. The blood is typically bright red, indicating fresh bleeding, and can be painless.
Severity of bleeding: The amount of bleeding can vary from spotting to massive hemorrhage, and it may start suddenly or gradually. Even a small amount of bleeding can be a sign of placenta previa and should not be ignored.
Risks of hemorrhage: Prompt recognition and management of bleeding are crucial to prevent potentially life-threatening hemorrhage for both the mother and the fetus.

Choice B rationale:
Severe pain with no bleeding is not a typical presentation of placenta previa. While some women with placenta previa may experience mild abdominal pain or cramping, severe pain without bleeding is more suggestive of placental abruption, a condition where the placenta prematurely separates from the uterine wall.

Choice C rationale:
High-grade fever is not a direct symptom of placenta previa. However, if a woman with placenta previa develops a fever, it could indicate an infection, which can further complicate the condition and require immediate medical attention.

Choice D rationale:
Sudden sharp pain in the lower abdomen can be a sign of placental abruption but is not characteristic of placenta previa.

A. Condition: Ovarian cysts, Finding: Ultrasound shows a fluid-filled sac in the ovary. B. Condition: Appendicitis, Finding: Pain localized in the lower right quadrant. C. Condition: Endometriosis, Finding: Patient reports cyclical pain. D. Condition: Pelvic inflammatory disease, Finding: Elevated white blood cell count.

Correct Answer is A

Explanation

Choice A rationale:
Ovarian cysts are fluid-filled sacs that form on or within an ovary. They are a common condition, affecting up to 1 in 5 women at some point in their lives. While most ovarian cysts are benign (non-cancerous), they can sometimes cause symptoms, including pelvic pain.
Ultrasound is a common imaging test that uses sound waves to create pictures of internal organs. It can be used to detect ovarian cysts, which often appear as fluid-filled sacs on the ovary.
The presence of an ovarian cyst on ultrasound, combined with the patient's symptoms of lower abdominal pelvic pain, suggests that the patient is at risk of developing complications from the cyst. These complications can include: Rupture: A ruptured ovarian cyst can cause sudden, severe pain and bleeding.
Torsion: This is when a cyst twists on its stalk, cutting off its blood supply. Torsion can also cause severe pain and may require emergency surgery.

Choice B rationale:
Appendicitis is an inflammation of the appendix, a small, finger-shaped organ located in the lower right abdomen. It is a common cause of abdominal pain, especially in young adults.

However, the patient in this scenario is experiencing pain in the lower abdominal pelvic region, not specifically in the lower right quadrant. This makes appendicitis less likely.
Additionally, the patient does not have any other symptoms that are typically associated with appendicitis, such as fever, nausea, or vomiting.

Choice C rationale:
Endometriosis is a condition in which tissue that normally lines the uterus grows outside of the uterus. It can cause pain, especially during menstruation.
However, the patient in this scenario does not report cyclical pain, which is a hallmark symptom of endometriosis. Additionally, endometriosis is not typically associated with the presence of fluid-filled sacs on the ovaries.

Choice D rationale:
Pelvic inflammatory disease (PID) is an infection of the upper genital tract, including the uterus, fallopian tubes, and ovaries. It is often caused by sexually transmitted infections (STIs).
PID can cause pelvic pain, but it is also typically associated with other symptoms, such as fever, vaginal discharge, and irregular bleeding.
The patient in this scenario does not have any of these other symptoms, and her white blood cell count is not elevated, which makes PID less likely.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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