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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will monitor my weight gain during the remaining months."
Correct: Monitoring weight gain during pregnancy is an appropriate action as it helps to ensure the baby's growth and overall health.
B. "I will use only nonprescription medications while pregnant."
Incorrect: This statement indicates a need for further teaching. Nonprescription medications may not be safe during pregnancy, as some overthecounter drugs can potentially harm the
fetus. It's essential for pregnant women to consult their healthcare provider before taking any medications.
C. "I will tell my doctor before using home remedies for nausea."
Correct: This statement shows the client's understanding that it's important to consult with their healthcare provider before using any home remedies during pregnancy, as some
remedies may not be safe for the developing fetus.
D. "I will reduce my stress level."
Correct: Managing stress during pregnancy is beneficial for both the mother and the baby. It indicates a good understanding of selfcare during pregnancy.
Correct Answer is A
Explanation
A. A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B. Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C. Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D. Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.
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