A nurse is caring for a client who is 35 weeks of gestation in the labor and delivery unit.
Based on the assessment findings, the physician plans to complete a BPP (biophysical profile). Which of the following is included in the BPP? (Select all that apply.)
Amniotic Fluid Index (AFI)
Fetal Breathing
Fetal Weight
Fetal Tone
Non-Stress Test (NST)
Fetal Movement
Correct Answer : A,B,D,E,F
Choice A rationale: Amniotic Fluid Index (AFI) assesses the amniotic fluid volume, an important indicator of fetal well-being. Normal AFI ranges from 5 to 24 cm. Abnormal levels may indicate potential complications such as oligohydramnios or polyhydramnios.
Choice B rationale: Fetal breathing movements are a key component of the biophysical profile, reflecting fetal central nervous system integrity. Typically observed for at least 30 seconds in a 30-minute period, absence may suggest hypoxia or CNS issues.
Choice C rationale: Fetal weight is not included in the BPP as it does not directly measure acute fetal well-being. It is assessed through ultrasound for growth monitoring and determining if the fetus is appropriate for gestational age.
Choice D rationale: Fetal tone evaluates fetal central nervous system function by observing limb or trunk movements. Normal tone includes flexion and extension movements, while decreased tone may indicate hypoxia or CNS dysfunction.
Choice E rationale: Non-Stress Test (NST) measures fetal heart rate accelerations in response to fetal movements. A reactive NST indicates fetal well-being, with at least two accelerations within 20 minutes, while a non-reactive NST may require further evaluation.
Choice F rationale: Fetal movement assessment involves counting gross body movements over a specified period. At least three movements in 30 minutes are considered normal, reflecting fetal CNS integrity. Decreased movement may indicate compromised fetal health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The gate control theory suggests that pain perception is not uniform and can be modulated by non-painful stimuli, such as touch or temperature, influencing the pain pathways.
Choice B rationale
The theory emphasizes that pain perception can be influenced by external factors, including psychological and physical interventions, not solely confined to the brain.
Choice C rationale
Pain signals can be modulated by stimulating other sensory nerves. For instance, massage or heat can activate non-nociceptive fibers, blocking pain signals at the spinal cord level.
Choice D rationale
Pain perception is not solely determined by tissue damage. The gate control theory highlights the modulation of pain by psychological and physical factors, showing that pain is a complex experience.
Correct Answer is A,B,C,D
No explanation
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