The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?
"I need to lie flat on my back to perform the procedure."
“If I count fewer than 10 kicks in a 2-hour period, I would count the kicks again over the next 2 hours."
"I need to place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."
“I will record the number of movements or kicks."
The Correct Answer is A
A. "I need to lie flat on my back to perform the procedure." Lying flat on the back can cause supine hypotension syndrome due to compression of the inferior vena cava. The client should lie on her left side or sit in a comfortable position to improve placental circulation.
B. “If I count fewer than 10 kicks in a 2-hour period, I would count the kicks again over the next 2 hours." If fewer than 10 movements are felt in 2 hours, the client should rest, eat, and try counting again. If movements remain low, she should contact her provider.
C. "I need to place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks." Placing hands on the abdomen helps the client feel subtle fetal movements.
D. “I will record the number of movements or kicks." Keeping a record of fetal movements helps monitor fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Feeling irregular contractions that become more frequent, longer, and stronger over time. This describes true labor contractions, which increase in intensity and frequency, leading to cervical changes.
B. Feeling less energetic and experiencing a decrease in Braxton Hicks contractions. Many clients experience a burst of energy (nesting) before labor, not decreased energy. A reduction in Braxton Hicks contractions is not a sign of impending labor.
C. Experiencing frequent urination and increased back pain. While these symptoms can occur due to fetal descent, they are not definitive signs that labor is starting.
D. Experiencing a decrease in vaginal discharge and a loss of the mucus plug. A loss of the mucus plug can occur days before labor, but it does not indicate labor is beginning immediately. Vaginal discharge often increases, not decreases, before labor.
Correct Answer is D
Explanation
A. A client who has a history of preterm labor. A history of preterm labor is not an indication for MSAFP screening. MSAFP is primarily used to detect neural tube defects (e.g., spina bifida) and chromosomal abnormalities (e.g., Down syndrome).
B. A client who has been exposed to AIDS. HIV/AIDS exposure does not impact MSAFP levels and is not an indication for the test. The focus in these clients is viral load monitoring and antiretroviral therapy.
C. A client who has mitral valve prolapse. Mitral valve prolapse does not affect fetal development in a way that would require MSAFP screening.
D. All of the clients. It is a standard screening test offered to all pregnant clients during the second trimester. The test is recommended for detecting fetal neural tube defects and certain chromosomal abnormalities, typically offered between 15-20 weeks of gestation.
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