The nurse is instructing a client on how to perform kick counts. ...

[jman1234]

The nurse is instructing a client on how to perform kick counts. Which information should the nurse include in the teaching session? (Select all that apply.)
 
  a. Use a clock or timer when performing kick counts.
  b. Your bladder should be full before performing kick counts.
  c. Notify your health care provider if you have not felt movement in 24 hours.
  d. Protocols can provide a structured timetable for concentrating on fetal movements.
  e. You should lie on your side, place your hands on the largest part of the abdomen, and concentrate on the number of movements felt.

Question 2

The nurse is preparing a client for a nonstress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.)
 
  a. Ensure that the client has a full bladder.
  b. Plan approximately 15 minutes for the test.
  c. Have the client sit in a recliner with the head elevated 45 degrees.
  d. Apply electronic monitoring equipment to the client's abdomen.
  e. Instruct the client to press an event marker every time she feels fetal movement.

[lkanara2]

Answer to Question 1

ANS: A, D, E
The nurse should instruct the client to lie on her side, place her hands on the largest part of her abdomen, and concentrate on fetal movements. She should use a clock or timer and record the number of movements felt during that time. Protocols are not essential but may give the client a more structured timetable for when to concentrate on fetal movements. The bladder does not need to be full for kick counts; it is better to have the client empty her bladder before beginning the assessment of fetal movements. Further evaluation is recommended if the client feels no movements in 12 hours; 24 hours is too long before notifying the health care provider.

Answer to Question 2

ANS: C, D, E
The client may be seated in a reclining chair or have her head elevated at least 45 degrees. The nurse applies external electronic monitoring equipment to the client's abdomen to detect the fetal heart rate and any contractions. The woman may be given an event marker to press each time she senses movement. Before the NST, the client should void and her baseline vital signs should be taken. The NST takes about 40 minutes, allowing for most fetal sleep-wake cycles, although the fetus may show a reassuring pattern more quickly or need more time to awaken and become active. Fifteen minutes would not allow enough time to complete the test.