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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Related Questions
Correct Answer is C
Explanation
This option respects the mother's wishes of not wanting to hold the newborn while also allowing the nurse to provide education on safe and appropriate feeding positions. It also gives the mother the opportunity to learn and practice holding the newborn in a safe way.
Option a, offering to take the newborn to the nursery, may not be necessary as the mother is already offering the baby a botle.
Option b, insisting that the mother pick up the newborn, would not be respectful of her wishes and could potentially damage the trust and rapport between the mother and nurse.
Option d, persuading the client to breastfeed, may not be appropriate or feasible in this situation as it may not be the mother's preferred feeding method and may not address the immediate concern of the newborn being too tired to be held.
Correct Answer is B
Explanation
Counterpressure is a technique that involves applying pressure to specific areas of the body during labor to help alleviate pain and discomfort. This technique is particularly helpful during the active phase of labor when contractions are strong and painful. The most common area to apply counterpressure is the lower back, as this is where many women experience the most intense pain during labor.
Option A “Your partner will apply pressure to the top of your uterus during contractions” is incorrect as applying pressure to the top of the uterus is not a recommended technique and could be harmful to the mother and the baby.
Option C “Your partner will apply continuous, firm pressure between your thumb and index finger” is incorrect as this technique is used to alleviate pain and discomfort during contractions in the hand and wrist, not for counterpressure.
Option D “Your partner will apply upward pressure on your lower abdomen between contractions” is incorrect as this technique is used to help turn a baby who is in a posterior position, not for counterpressure.
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