NCLEX-PN

Category - Health Promotion

The nurse is monitoring the well-being of a 30-week old fetus through a non-stress test. After 20 minutes, no fetal movements were detected. Which of the following is the immediate action of the nurse?
  1. Contact the registered nurse
  2. Assist the client in side-lying position
  3. Give the mother a glass of orange juice
  4. Ask the mother to void urine
Explanation
Answer: C - If 20 minutes have passed and no fetal movement is detected, the immediate action of the nurse is to offer the mother a high-carbohydrate snack, such as an orange juice. Lack of movements may indicate that the fetus is sleeping and giving a carbohydrate snack increases the blood glucose high enough to stimulate fetal movements.
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