A nurse is caring for a client at 38 weeks gestation who arrived to the triage with complaints of decreased fetal movement.
The nurse contacts the provider and reports the findings.
The nurse anticipates an order for which of the following?
Non-stress test.
Biophysical profile.
Ultrasound.
Amniocentesis.
The Correct Answer is A
Choice A rationale
A non-stress test (NST) is a common initial assessment for decreased fetal movement. It evaluates fetal heart rate patterns in response to fetal movements, providing information about fetal well-being and oxygenation.
Choice B rationale
A biophysical profile (BPP) is a more comprehensive assessment that includes an NST and ultrasound evaluation of fetal movements, tone, breathing, and amniotic fluid volume. It may be ordered if the NST results are non-reassuring or if there are other concerns.
Choice C rationale
An ultrasound can provide valuable information about fetal growth, amniotic fluid volume, and placental function. It may be used in conjunction with other tests but is not the first-line assessment for decreased fetal movement.
Choice D rationale
Amniocentesis is an invasive procedure used for specific indications, such as genetic testing or assessing fetal lung maturity. It is not typically used for initial assessment of decreased fetal movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Category I tracings are considered normal and are associated with a well-oxygenated, non-acidotic fetus with a normal fetal heart rate baseline, moderate variability, and no late or variable decelerations. However, a baseline heart rate of 175 bpm is considered tachycardia, which does not fit the criteria for Category I.
Choice B rationale
Category II tracings are indeterminate and include any fetal heart rate pattern that does not fit into Category I or III. A baseline heart rate of 175 bpm with moderate variability and no accelerations or decelerations fits into this category. This indicates that the fetus may be experiencing some stress but is not in immediate danger.
Choice C rationale
Category III tracings are abnormal and are associated with an increased risk of fetal acidemia. These tracings include absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern. The given tracing does not meet these criteria as it shows moderate variability and no decelerations.
Choice D rationale
There is no Category IV in the classification of fetal heart rate tracings. The standard classification includes only Categories I, II, and III.
Correct Answer is C
Explanation
Choice A rationale
A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.
Choice B rationale
A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.
Choice C rationale
Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.
Choice D rationale
Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.
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