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

While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.

Choice B rationale

Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.

Choice C rationale

Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.

Choice D rationale

Assessing temperature every hour is not specifically related to the care of a client with eclampsia.

A. Swaddle the infant in a warm blanket. B. Document the findings in the record. C. Place a pulse oximeter on the infant’s heel. D. Obtain a heel stick blood glucose level.

Correct Answer is D

Explanation

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

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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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Naxlex Comprehensive Predictor Exams

A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.She is not currently convulsing.What intervention should the nurse plan to include in this client’s nursing care plan?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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