A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
Percutaneous umbilical blood sampling
Amnioinfusion
Biophysical profile (BPP)
Chorionic villus sampling (CVS)
The Correct Answer is C
Choice A Reason:
Percutaneous umbilical blood sampling (PUBS) is not appropriate. This invasive procedure involves sampling blood from the umbilical cord and is not typically used in the context of a positive contraction stress test.
Choice B Reason:
Amnioinfusion is not appropriate. Amnioinfusion is a procedure in which sterile fluid is infused into the amniotic cavity to alleviate conditions such as oligohydramnios. It is not a primary diagnostic test for assessing fetal well-being.
Choice C Reason:
Biophysical profile (BPP) is appropriate. The biophysical profile is a diagnostic test that assesses the well-being of the fetus by evaluating various parameters, including fetal heart rate, fetal breathing movements, fetal movements, fetal tone, and the amniotic fluid volume. This test provides additional information to assess fetal well-being and can help guide decisions about the timing and mode of delivery.
Choice D Reason:
Chorionic villus sampling (CVS) is inappropriate. CVS is a prenatal test used for diagnosing certain genetic conditions but is not indicated in the context of a positive contraction stress test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
A. Maintain the client NPO throughout the procedure: It is not necessary to maintain the client NPO (nothing by mouth) for a nonstress test. The test primarily involves monitoring fetal heart rate in response to the baby's movements and does not require fasting.
B. Place the client in a supine position: Placing the client in a left lateral position is often preferred for NST to optimize uterine blood flow and fetal oxygenation. The supine position can compromise blood flow to the uterus and is generally avoided, especially in later pregnancy.
C. Instruct the client to massage the abdomen to stimulate fetal movement: While the goal of the NST is to monitor fetal movements, instructing the client to actively stimulate fetal movement through abdominal massage is not a standard part of the procedure. Fetal movements should occur naturally.
D. Instruct the client to press the provided button each time fetal movement is detected: This is the correct action. During a nonstress test, the client is typically provided with a button to press whenever she feels fetal movement. This helps correlate fetal movements with changes in the fetal heart rate on the monitor, providing valuable information about the baby's well-being.
Correct Answer is C
Explanation
The correct answer is C. Continuous contraction lasting 2 min.
A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.
B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.
C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.
A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.
D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.
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