Nokea
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
- A. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results.
- B. Maintain NPO status prior to testing.
- C. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
- D. Have an infusion pump prepared with oxytocin per protocol for evaluation.
Correct Answer: C
Rationale: The correct answer is C because positioning the patient for comfort and adjusting the tocotransducer belt to locate fetal heart rate are essential steps in preparing a pregnant patient for a nonstress test (NST). This allows for proper monitoring of fetal heart rate without interference.
A: Having the patient void prior to the test is not necessary for an NST as a full bladder does not interfere with the results.
B: Maintaining NPO status is not required for an NST, as it does not involve any invasive procedures that would necessitate fasting.
D: Preparing an infusion pump with oxytocin is not part of the standard preparation for an NST and is not needed for evaluation.
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Without doing a vaginal examination, a nurse concludes that a primigravida, who has received no medications during her labor, is in transition. Which of the following signs/symptoms would lead a nurse to that conclusion?
- A. The woman fell asleep during a contraction.
- B. The woman yelled at her partner and vomited.
- C. The woman laughed at something on the television.
- D. The woman began pushing with each contraction.
Correct Answer: B
Rationale: Yelling and vomiting are common signs of the transition phase of labor, characterized by intense contractions and emotional distress.
During a postpartum examination, the nurse notes that a client’s left calf is warm and swollen. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the client’s physician.
- B. Teach the client to massage her leg.
- C. Apply ice packs to the client’s leg.
- D. Encourage the client to ambulate.
Correct Answer: A
Rationale: A warm, swollen calf may indicate deep vein thrombosis (DVT), a serious condition requiring immediate medical attention.
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.
The nurse reports a nonreactive NST to the physician. The physician orders vibroacoustic stimulation. Which does the nurse understand the appropriate application for the vibroacoustic stimulation to be? Select all that apply.
- A. Clap loudly by the fetal head
- B. Apply a sterile drape to abdomen prior to stimulation
- C. Apply the artificial larynx stimulus by the fetal head
- D. Limit the use of the artificial larynx stimulus to three times
Correct Answer: C
Rationale: The correct answer is C: Apply the artificial larynx stimulus by the fetal head. Vibroacoustic stimulation involves using sound waves to stimulate the fetus and provoke a response, particularly in cases of nonreactive nonstress test (NST). By applying the artificial larynx stimulus near the fetal head, the nurse ensures direct and effective stimulation of the fetus. This method has been found to be safe and effective in improving fetal heart rate reactivity.
Incorrect Choices:
A: Clap loudly by the fetal head - This is not an appropriate method for vibroacoustic stimulation as it may not provide the controlled and targeted stimulation needed.
B: Apply a sterile drape to abdomen prior to stimulation - This is not necessary for vibroacoustic stimulation and does not contribute to its effectiveness.
D: Limit the use of the artificial larynx stimulus to three times - There is no specific limit to the number of times vibroacoustic stimulation can be applied, as it depends on the
The nurse is discussing the methods of confirming the pregnancy with a patient at the first prenatal visit. What method is used to confirm cardiac activity of the fetus?
- A. bimanual exam
- B. pelvic ultrasound
- C. serum pregnancy test
- D. urine pregnancy test
Correct Answer: B
Rationale: The correct answer is B: pelvic ultrasound. Pelvic ultrasound is used to confirm the presence of cardiac activity in the fetus by visualizing the fetal heartbeat. This method is the most accurate and reliable way to confirm the viability of the pregnancy. A bimanual exam (choice A) is a physical examination technique that assesses the size and shape of the uterus but does not confirm fetal cardiac activity. Serum pregnancy test (choice C) and urine pregnancy test (choice D) detect the presence of human chorionic gonadotropin (hCG) hormone in the blood or urine, indicating pregnancy, but do not confirm fetal cardiac activity.