Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
52. A client, who is a primigravida at 39 weeks' gestation, is being instructed on when she should come to the hospital. Which instructions should a nurse include?
Select all that apply.
. "Come to the hospital if you are feeling decreased fetal movement."
. "Come to the hospital when the contractions are regular, about 5 minutes apart, lasting about 60 seconds."
. "Come to the hospital when you think your amniotic fluid is leaking."
. "Come to the hospital when you feel increased fetal movement."
. "Come to the hospital when the contractions are 10–15 minutes apart lasting about 30 seconds."
Test-Taking Tip
Look for pairs of answers that are opposite of each other and eliminate one of them in each "pair." Select Answer 1 and therefore eliminate Answer 4. Select Answer 2 and therefore eliminate Answer 5.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . .
Answer 1 is correct because decreased fetal movement may be an indication of fetal hypoxia, and the fetus should be evaluated using an external fetal monitor. Answer 2 is correct because contractions that are regular, every 5 minutes, and lasting 60 seconds are usually indicative of active labor, and the client should come to the hospital to be evaluated for labor. Answer 3 is correct because, if the client thinks her amniotic fluid is leaking, she should be evaluated for rupture of membranes and labor. Answer 4 is incorrect because increased fetal movement is a reassuring sign, and the client does not need to come to the hospital to evaluate the fetal well-being. Answer 5 is incorrect because contractions that are 10 minutes apart, only lasting for 30 seconds, are usually associated with the latent phase of labor, and the client does not need to come to the hospital for evaluation of labor.