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 D

Explanation

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Routinely inserting an indwelling urinary catheter is not necessary for maintaining an empty bladder during labor. While it is important to ensure the client has a voiding schedule, the use of an indwelling catheter should be reserved for specific medical indications, such as when the client is unable to void or has received an epidural. Indwelling catheters can increase the risk of catheter-associated urinary tract infections (CAUTIs) and should be used judiciously.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Keeping all four side rails up and maintaining strict bedrest is not appropriate during active labor. This practice can limit the client’s movement, which is essential for comfort and progress during labor. Movement and changing positions can help labor progress and reduce pain. Strict bedrest is generally reserved for specific medical conditions, such as preterm labor or other complications.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus. However, hourly monitoring may not be sufficient. Guidelines recommend more frequent monitoring, typically every 15-30 minutes during the active phase of labor and every 5-15 minutes during the second stage. Continuous electronic fetal monitoring may be used for high-risk pregnancies or if there are signs of fetal distress.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Checking the cervix to determine how close the time of delivery may be prior to analgesic administration is important. This practice helps ensure that analgesics are administered at an appropriate time, avoiding potential complications such as delayed delivery or inadequate pain relief. Cervical checks provide valuable information about the progress of labor and help guide clinical decisions regarding pain management and delivery planning.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

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 in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of 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?

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?