A nurse is caring for a client during a nonstress test (NST). At the end of a 30min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following
interpretations of these findings should the nurse make?

A reactive test

A negative test

A positive test

A nonreactive test

Answer and Explanation

The Correct Answer is D

A) A reactive test: A reactive NST requires the presence of specific criteria, including at least two fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting for at least 15
seconds in a 20minute period, along with a baseline heart rate within the normal range (110160 bpm) and moderate variability.
B) A negative test: "Negative" is not a term used to describe NST results.

C) A positive test: "Positive" is not a term used to describe NST results.

D) A nonreactive test: This is the correct interpretation. In a nonreactive NST, the fetal heart rate did not demonstrate the required accelerations within the 30minute observation period. The absence of accelerations can indicate potential fetal compromise, and further evaluation, such as a contraction stress test or biophysical profile, may be necessary to assess the fetus's wellbeing.

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Correct Answer is B

Explanation

Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.

Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.

Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.

Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.

A. "I will have to lie on my back during the test." B. "My baby's heart rate will be monitored during the test." C. "It will take 20 to 30 minutes to complete the test." D. "I should schedule the test when the baby is usually active."

Correct Answer is A

Explanation

Choice A: The client should not lie on her back during the NST because the supine position can compress the vena cava and reduce blood flow to the placenta and the baby. The NST is typically done with the client in a semireclined or left lateral position to ensure optimal blood flow to the baby.

Choice B: Monitoring the baby's heart rate is a correct statement and a standard part of the NST procedure.

Choice C: The duration mentioned (20 to 30 minutes) is accurate for the average NST timeframe.

Choice D: Scheduling the NST when the baby is usually active is also a correct statement, as fetal movement during the test is an important aspect of evaluating fetal wellbeing.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an ROA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. The nurse uses Naegele's Rule to calculate the correct EDD:

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone (Cervidil) gel. Which of the following statements should the nurse include in the teaching?