A patient who is 36 weeks pregnant tells you she has been counting her baby's kicks and is concerned because within a 4-hour period the baby has only kicked 32 times.
What nursing intervention is correct?
Assess the patient's urine for protein and glucose.
Prep the patient for an abdominal ultrasound.
Reassure the patient this kick count is normal.
Notify the MD of this finding.
The Correct Answer is D
Choice A rationale
Assessing the patient's urine for protein and glucose is relevant for evaluating potential preeclampsia or gestational diabetes, but it does not directly address the immediate concern of decreased fetal movement. While these conditions can indirectly affect fetal well-being, the priority is to assess fetal status directly.
Choice B rationale
Preparing the patient for an abdominal ultrasound can provide information about fetal well-being and amniotic fluid volume, but it is not the immediate first-line intervention for a concerning decrease in fetal kick counts. Further assessment is needed before resorting to diagnostic procedures.
Choice C rationale
A kick count of 32 movements in 4 hours is below the generally accepted normal range. While definitions vary slightly, many healthcare providers consider fewer than 10 movements in 2 hours or a significant decrease from the patient's baseline to be concerning and warrant further investigation. Reassuring the patient without further assessment would be inappropriate.
Choice D rationale
A decrease in fetal movement can be a sign of fetal distress and requires prompt evaluation by a healthcare provider. Notifying the physician or midwife is the correct priority nursing intervention to initiate further assessment of fetal well-being, which may include a non-stress test (NST) or biophysical profile (BPP).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.
Choice B rationale
Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.
Choice C rationale
Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.
Choice D rationale
Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.
Correct Answer is A
Explanation
Choice A rationale
True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.
Choice B rationale
The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.
Choice C rationale
Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.
Choice D rationale
A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.
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