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 C

Explanation

The correct answer is choice C. Urine testing is the best indication of whether my blood sugar is under control. This is wrong because urine testing only reflects the blood sugar level at the time of urination, not the current level.

It also does not detect low blood sugar levels (hypoglycemia), which can be dangerous for the mother and the baby.

The best way to monitor blood sugar levels during pregnancy is to use a glucometer, which measures the blood glucose level from a drop of blood.

Choice A is correct because insulin requirements usually increase during pregnancy due to hormonal changes and increased insulin resistance.

The patient may need to adjust her insulin dose according to her blood glucose levels and dietary intake.

Choice B is correct because the patient needs to eat a balanced diet that provides adequate calories and nutrients for herself and the baby.

She may need to consult a dietitian to plan her meals and snacks according to her blood glucose levels and insulin regimen.

Choice D is correct because regular exercise can help lower blood glucose levels, improve insulin sensitivity, and prevent excessive weight gain during pregnancy.

The patient should consult her healthcare provider before starting or changing her exercise routine.

A. The newborn’s nostrils flare slightly during respiration. B. The newborn’s hands and feet are blue and feel cool. C. The newborn’s eyes move randomly when his head is turned to the side. D. The newborn’s tongue thrusts forward when it is lightly touched.

Correct Answer is A

Explanation

The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.

Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.

Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.

It usually resolves within 24 to 48 hours after birth.

Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.

It usually disappears by 6 months of age.

Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.

It usually fades by 4 months of age.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a newborn. Which finding may indicate a problem?

Correct Answer is A

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?