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NurseDive Free Nursing Practice Question
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?
A. Immediately report the situation to the client's provider and prepare the client for induction of labor.
Reporting the situation and preparing the client for induction of labor is not the first action to take. Turning the client onto her left side is the initial intervention to stimulate fetal movements.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.
Encouraging the client to walk around without the monitoring unit is not appropriate in this situation, as the NST requires continuous monitoring of the fetal heart rate.
C. Turn the client onto her left side.
During a nonstress test (NST), the nurse monitors the fetal heart rate in response to fetal movements. Absence of fetal movements for 15 minutes can be concerning and might not provide adequate information for the NST. The first intervention should be to encourage fetal movement by turning the client onto her left side, which can improve blood flow to the uterus and increase fetal activity.
D. Offer the client a snack of orange juice and crackers
Offering the client a snack of orange juice and crackers might be done as a noninvasive intervention to encourage fetal movements, but turning the client onto her left side is more effective and should be done first.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Exam - Proctored Exam 2. Take the full exam now
Full Explanation
A. Immediately report the situation to the client's provider and prepare the client for induction of labor. This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.
C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.
D. Offer the client a snack of orange juice and crackers. This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.
Similar Questions
A nurse is providing dietary education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?
A. "I should not drink alcoholic beverages during my pregnancy."
"I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
B. "I should drink about 2 liters of fluid each day."
"I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
C. "I can have a moderate amount of caffeine daily."
"I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
D. "I should increase my intake of all kinds of fish throughout my pregnancy."
During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
Full Explanation
Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?
A. Temperature 38.2°C (100.8°F)
Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B. The client reports reduced sensation of the lower extremities.
Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C. The client reports generalized itching.
Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D. Blood pressure 80/52 mm Hg
Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.
Full Explanation
A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.
A nurse in a prenatal clinic is caring for a client who states that she might be pregnant because she feels the baby moving. How does the nurse classify this statement by the client?
A. "This is a presumptive sign of pregnancy."
Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.
B. "This is a positive sign of pregnancy."
Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.
C. "This is a probable sign of pregnancy."
Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.
D. "This is a potential sign of pregnancy."
"Potential sign of pregnancy" is not a recognized classification in pregnancy signs.
Full Explanation
A: Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.
B: Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.
C: Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.
D: "Potential sign of pregnancy" is not a recognized classification in pregnancy signs.