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.
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Related Questions
Correct Answer is D
Explanation
A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.
Correct Answer is C
Explanation
Choice A: Fetal movements, also known as quickening, are usually felt by the mother between weeks 18 and 25 of pregnancy, not specifically at week 24.
Choice B: While the sex of the baby is determined at conception, it is not visually identifiable on ultrasound until around week 16 to 20, depending on the fetus's position and the quality of the ultrasound images.
Choice C: The baby's heartbeat can be visualized on ultrasound as early as 6 weeks of pregnancy. It becomes audible using a Doppler stethoscope around 8 to 9 weeks of pregnancy.
Choice D: Lanugo, the fine hair covering the baby's body, usually appears around weeks 20 to 24 of pregnancy and begins to diminish later in pregnancy, not specifically at week 36.
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