A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
Three fetal movements perceived by the client in a 20 min testing period
No late decelerations in the foetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
An increase in foetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to foetal movement within a 40-min testing period
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
The Correct Answer is A
A nonstress test measures fetal heart rate in response to fetal movement. A reactive nonstress test result is when there are at least two accelerations of the fetal heart rate within a 20-minute period, each lasting at least 15 seconds and peaking at least 15 beats per minute above the baseline. If there are fewer than two accelerations within a 20-minute period, further diagnostic testing may be needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.
Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.
Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.
Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.
Correct Answer is C
Explanation
Pregnant clients with HIV require comprehensive care during pregnancy, delivery, and postpartum periods to prevent transmission of HIV to the newborn. Bathing the newborn before initiating skin-to-skin contact is a recommended action to reduce the risk of HIV transmission from mother to child. This practice helps to remove any maternal blood or other bodily fluids from the newborn's skin, which may contain the virus. Therefore, the nurse should instruct the client to bathe the newborn before initiating skin-to-skin contact.
Antiretroviral medications are usually continued throughout pregnancy and during labor and delivery to decrease the risk of transmission to the newborn. Therefore, the nurse should not instruct the client to stop taking antiretroviral medications at 32 weeks of gestation, as mentioned in option a.
Fetal scalp electrode is a device that ataches to the baby's scalp to monitor the fetal heart rate. This device can cause small cuts or abrasions on the baby's scalp, which may increase the risk of HIV transmission.
Therefore, its use should be avoided in clients with HIV. Therefore, option b is not a recommended action.
Administering pneumococcal immunization to the newborn within 4 hours following birth is not a recommended action in the plan of care for a client who is pregnant and has HIV. Pneumococcal immunization is not indicated for newborns immediately after birth. Therefore, option d is not a recommended action.
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