A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143.
Which action should the nurse take?

Ask the patient if she has had any alcoholic beverages within the past 24 hours.

Find out if the patient has had any bloody vaginal discharge today.

Tell the patient that the fetal heart rate does not appear to indicate that the baby is in distress.

Explain to the patient the relationship between a woman's anxiety level and her ability to detect movement.

Answer and Explanation

The Correct Answer is C

This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.

Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.

Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.

Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.

It does not indicate fetal distress or placental abruption.

Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.

Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.

The nurse should validate the patient’s feelings and provide factual reassurance.

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Correct Answer is A

Explanation

The correct answer is choice A. The client is trying to reassure herself concerning the present situation.This is a common coping strategy for women who face the risk of preterm labor and delivery.The client may be experiencing fear, anxiety, or denial about the possible outcomes of her pregnancy.

Choice B is wrong because coping as expected in this situation implies that there is a normal or standard way of coping with preterm labor, which is not true.Different women may cope differently depending on their personal, social, and emotional factors.

Choice C is wrong because anxious to see the new baby does not reflect the client’s statement.

The client is not expressing excitement or eagerness about the birth, but rather a rationalization that everything will be okay despite the risks.

Choice D is wrong because able to use previously learned knowledge in a new situation does not apply to the client’s statement.

The client is not using her sister’s experience as a source of information or guidance, but rather as a way of minimizing or dismissing her own situation.

A. Obtain a full history. B. Examine the cervix for dilation C. Examine the cervix for dilation. D. Palpate for uterine contraction frequency

Correct Answer is C

Explanation

This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.

Choice A: Obtain a full history is wrong because it is not the most urgent action.

A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.

Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.

Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.

Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.

Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.

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A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried. My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143.
Which action should the nurse take?