A nurse is conducting a nipple-stimulated contraction stress test (CST) for a client who had a nonreactive nonstress test (NST).
Which of the following instructions should the nurse give to the client for this test?
“You will need to fast for 8 hours before the test.”
“You will need to drink orange juice before the test.”
“You will need to brush your nipple with your palm for 2 minutes.”
“You will need to lie on your back during the test.”
The Correct Answer is C
The nurse should instruct the client to brush her nipple with her palm for 2 minutes.
This will stimulate the release of oxytocin and cause uterine contractions. The fetal heart rate (FHR) will be monitored for any signs of fetal distress, such as decelerations.
Choice A is wrong because fasting is not required for a CST. Fasting may be necessary for other tests that involve anesthesia or sedation.
Choice B is wrong because drinking orange juice will not induce contractions. Orange juice may be given to increase fetal activity before a nonstress test (NST), which measures the FHR response to fetal movement.
Choice D is wrong because lying on the back can compress the inferior vena cava and reduce blood flow to the uterus and the fetus. The client should lie on her side during the test to prevent supine hypotension syndrome.
Normal ranges for FHR are 110 to 160 beats per minute, with moderate variability and no decelerations. Normal ranges for uterine contractions are less than five in a 10-minute period, lasting less than 90 seconds each.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reactive.This means that the fetal heart rate (FHR) accelerates at least 10 beats/min for at least 10 seconds two or more times in a 30-minute period.This result shows that the baby is getting enough oxygen and is doing well.
Nonreactive.
This means that the FHR does not accelerate as expected during the test.This result does not necessarily mean that there is a problem, but it may indicate that the baby is not getting enough oxygen or is asleep.
If this happens, more tests may be needed.
Unsatisfactory.This means that the test results are unclear or incomplete due to technical problems or poor quality of the recording.
If this happens, the test may need to be repeated.
Equivocal.This means that the test results are uncertain or inconclusive due to factors such as preterm gestation, fetal sleep, maternal medications, or fetal anomalies.
If this happens, more tests may be needed.
Normal ranges for FHR are between 110 and 160 beats/min at rest and between 120 and 180 beats/min during movement.
Correct Answer is C
Explanation
Explain the purpose, procedure, and possible outcomes of the test to the client.This is because the nurse should always obtain informed consent from the client before performing any procedure, and provide education and reassurance about the test.
Choice A is wrong because applying conduction gel to the client’s abdomen is not the first action the nurse should take.The nurse should first explain the test and obtain consent from the client before applying any equipment.
Choice B is wrong because instructing the client to press a button when she feels fetal movement is part of the nonstress test procedure, but not the first action.The nurse should first educate the client about the test and its purpose.
Choice D is wrong because activating a vibroacoustic stimulation device to wake up the fetus is not necessary for a nonstress test.This device may be used if the fetal heart rate is nonreactive, but only after explaining the test and obtaining consent from the client.
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