A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

Avoid caffeinated drinks for 24 hours before conducting the kick test.

Exercise for 15 minutes before starting the counting to help increase fetal movement.

Count the movements once daily, for one hour, before breakfast.

If 10 kicks are not felt within one hour, drink orange juice and count for another hour.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine does not significantly affect fetal movements.

Choice B rationale

Exercising for 15 minutes before starting the counting to help increase fetal movement is not a standard recommendation. While physical activity can sometimes stimulate fetal movement, it’s not a requirement for performing kick counts.

Choice C rationale

Counting the movements once daily, for one hour, before breakfast is not the standard recommendation. The best time to do kick counts is when the baby is usually most active, which might be after a meal, early in the morning, or at another point in the day.

Choice D rationale

If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn’t feel 10 movements within 2 hours, she should contact her healthcare provider.

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Correct Answer is B

Explanation

Choice A rationale

Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.

Choice B rationale

An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.

Choice C rationale

Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.

Choice D rationale

Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.

A. Estimated amount of fluid. B. Any odor noted when membranes ruptured. C. Time the membranes ruptured. D. Color and consistency of fluid.

Correct Answer is C

Explanation

Choice A rationale

While the estimated amount of fluid can provide some information about the volume of amniotic fluid lost, it is not the most critical piece of information. The amount of fluid can vary and does not necessarily indicate the progression of labor.

Choice B rationale

Any odor noted when the membranes ruptured can be a sign of infection. However, this is not the most crucial information to obtain immediately as it does not directly impact the management of labor.

Choice C rationale

The time the membranes ruptured is the most important information to obtain. This is because the risk of infection increases the longer the time between membrane rupture and delivery.

Knowing the time of rupture helps guide decisions about inducing labor and administering antibiotics to prevent infection.

Choice D rationale

The color and consistency of the fluid can provide information about the presence of meconium or blood, which could indicate fetal distress or placental problems. However, this is not the most critical information to obtain immediately.

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A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

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Correct Answer is B

Explanation

A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

Correct Answer is C

Explanation

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