A nurse is assisting with a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "What are you looking for during this test?" Which of the following responses should the nurse make?
"We are looking for increases in fetal heart rate of 15/min for at least 15 seconds. This means the baby is doing well."
"We will draw blood to evaluate the baby's risk of genetic problems."
"I am looking at the ultrasound to see if the baby has any congenital anomalies."
"If the baby moves 5 times in 15 minutes, then the baby is healthy."
The Correct Answer is A
A. "We are looking for increases in fetal heart rate of 15/min for at least 15 seconds. This means the baby is doing well." – Correct; a reactive NST shows at least two accelerations of 15 bpm lasting at least 15 seconds within 20 minutes, indicating fetal well-being.
B. "We will draw blood to evaluate the baby's risk of genetic problems." – Incorrect; an NST does not involve blood work; genetic testing is done through amniocentesis or blood screening.
C. "I am looking at the ultrasound to see if the baby has any congenital anomalies." – Incorrect; an NST does not evaluate congenital anomalies; an ultrasound or amniocentesis would be used for that.
D. "If the baby moves 5 times in 15 minutes, then the baby is healthy." – Incorrect; fetal movement is assessed with kick counts, not an NST.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fundus soft, 2 fingerbreadths below the umbilicus – Incorrect; the fundus should be firm, not soft, to prevent postpartum hemorrhage.
B. Fundus firm, 2 fingerbreadths above the umbilicus – Incorrect; a fundus above the umbilicus at 12 hours may indicate bladder distension or uterine atony.
C. Fundus soft, to the right of the umbilicus – Incorrect; a deviated and soft fundus suggests bladder distension, requiring intervention.
D. Fundus firm, at the level of the umbilicus – Correct; at 12 hours postpartum, the fundus should be firm and at the level of the umbilicus, gradually decreasing in height each day.
Correct Answer is D
Explanation
A. Decreased response with sexual activity – Incorrect; decreased libido is common postpartum and not an urgent concern.
B. A scant non-odorous white vaginal discharge – Incorrect; lochia alba (whitish discharge) is normal at 4 weeks postpartum.
C. Uterine cramping during breastfeeding – Incorrect; cramping (due to oxytocin release) is expected postpartum.
D. A moderate serosanguineous malodorous discharge – Correct; foul-smelling lochia can indicate endometritis (a postpartum infection).
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