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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C.Choice C is wrong because having more than three full-term pregnancies does not affect the suitability of using a copper IUD as a birth control method.Copper IUDs are long-term, reversible contraceptives that can be used by premenopausal women of all ages, including those who have never been pregnant or who have had multiple pregnancies.
Choice A is correct because a copper IUD can be inserted anytime during a normal menstrual cycle, or up to eight weeks after childbirth.
Choice B is correct because a copper IUD may cause heavier and longer periods, as well as more cramping.
Choice D is correct because a copper IUD works by creating an inflammatory response in the uterus that prevents sperm from reaching the egg and fertilizing it, and also prevents a fertilized egg from implanting in the uterine wall.
Correct Answer is C
Explanation
The correct answer is choice C. The woman’s temperature will increase when she is ovulating.This is because ovulation is triggered by a surge of luteinizing hormone (LH), which also causes a slight rise in basal body temperature (BBT).By measuring her BBT every morning before getting out of bed, the woman can detect this subtle change and identify her fertile window.
Choice A is wrong because ovulation typically occurs around 14 days before the next menstrual period, not seven days after the previous one.
The length of the menstrual cycle can vary from woman to woman, so counting days is not a reliable method of predicting ovulation.
Choice B is wrong because cervical mucus will appear clear, slippery and stretchy when the woman is ovulating, not tacky and cloudy.
This type of mucus helps sperm swim and survive in the reproductive tract.
The woman can check her cervical mucus by wiping with toilet paper or inserting a finger into her vagina.
Choice D is wrong because abdominal massage of the ovaries will not stimulate ovulation, and may even cause harm by injuring the delicate tissues or introducing infection.
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