A nurse is caring for a term newborn male client who is 72 hours old in the neonatal intensive care unit. The newborn was born after a precipitous vaginal birth at 39 weeks of gestation. The mother has a history of opioid use during pregnancy.

Exhibits

The nurse is assessing the newborn 24 hours later. For each finding, specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Choice A rationale
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client during a nonstress test may indicate a need for further diagnostic testing. These could be Braxton Hicks contractions, which are normal, but if they become regular and increase in intensity, they could indicate preterm labor.
Choice B rationale
An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding on a nonstress test. This is known as a reactive nonstress test and indicates that the fetus is well-oxygenated.
Choice C rationale
No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is a normal finding on a nonstress test. Late decelerations can indicate fetal hypoxia.
Choice D rationale
Three fetal movements perceived by the client in a 20-min testing period is a normal finding on a nonstress test. Fetal movement is a positive sign of fetal well-being.

Choice A rationale
A previous delivery at 37 weeks gestation does not necessarily indicate a risk for preterm delivery. Preterm delivery is defined as delivery before 37 weeks of gestation.
Choice B rationale
A previous delivery of a newborn weighing 2.5 kg (5.5 lb) does not indicate a risk for preterm delivery. Low birth weight can be a result of preterm delivery, but it can also be due to other factors such as intrauterine growth restriction.
Choice C rationale
A previous reactive non-stress test does not indicate a risk for preterm delivery. A reactive non-stress test is a positive sign of fetal well-being.
Choice D rationale
A previous cervical cerclage indicates a risk for preterm delivery. Cervical cerclage is a procedure performed to prevent preterm birth in women with a history of preterm birth and who have a short cervix.