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.

Answer and Explanation

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).

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Correct Answer is B

Explanation

Choice A rationale

Elevating the mother's legs may help with venous return and circulation, but it does not directly address a soft and boggy uterus, which indicates uterine atony and a risk for hemorrhage. The immediate priority is to promote uterine contraction.

Choice B rationale

A soft and boggy uterus indicates uterine atony, a primary cause of postpartum hemorrhage. Massaging the fundus stimulates the uterine muscles to contract, which helps to compress the blood vessels at the placental site and reduce bleeding. This is the most appropriate initial intervention to address uterine atony.

Choice C rationale

Encouraging the mother to void is important in the postpartum period as a full bladder can displace the uterus and interfere with its ability to contract. However, in the presence of a soft and boggy uterus, the immediate priority is to directly stimulate uterine contraction through fundal massage before addressing bladder emptying.

Choice D rationale

Pushing on the uterus to express clots without first ensuring the uterus is firm is contraindicated. A soft, atonic uterus is more susceptible to inversion if pressure is applied. Fundal massage should be performed first to encourage uterine contraction and firmness before attempting to express any clots.

A. "Because blood pressure often increases early in the second trimester of pregnancy.”. B. "You are at an increased risk for high blood pressure since you've had several pregnancies.”. C. "Your age is a risk factor for developing high blood pressure during pregnancy.”. D. "No need to worry about that, let's talk about how you're feeling.”.

Correct Answer is C

Explanation

Choice A rationale

While blood pressure can increase during the second trimester due to changes in the maternal cardiovascular system, it doesn't typically increase *early* in the second trimester. Physiologic changes usually lead to a slight decrease in blood pressure during the first and early second trimester before gradually returning to pre-pregnancy levels or potentially increasing later.

Choice B rationale

While multiparous women can develop gestational hypertension or preeclampsia, having had "several pregnancies" in the past does not inherently increase the risk of high blood pressure at 14 weeks gestation in the current pregnancy, especially if previous pregnancies were normotensive. Risk factors like age, pre-existing conditions, and family history are more significant.

Choice C rationale

Advanced maternal age, generally considered 35 years or older, is a known risk factor for developing gestational hypertension and preeclampsia during pregnancy. Physiological changes associated with aging can affect vascular function and increase susceptibility to hypertensive disorders.

Choice D rationale

While addressing the client's feelings is important for therapeutic communication, it avoids answering her direct question about why her blood pressure is being taken. The nurse has a responsibility to provide accurate information regarding routine assessments during pregnancy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period.When the nurse locates the fundus, she notes that the uterus feels soft and boggy at midline.Which of the following nursing interventions would be most appropriate initially?

Correct Answer is B

Explanation

A nurse is caring for a 37-year-old G3P2 client who is at 14 weeks of gestation. The client asks, "why are you taking my blood pressure? It's always been normal.”. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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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?