A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?

An FHR that peaks 20 beats above the baseline.

Three uterine contractions within a 20-min period.

One acceleration of the FHR within a 20-min period.

Uterine contractions lasting 20 to 30 seconds each.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. One acceleration of the FHR within a 20-min period.

Here's the rationale for each choice:

Choice A: Rationale: A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.

Choice B: Rationale: While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.

Choice C: Rationale: A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.

Choice D: Rationale: Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.

Choice B rationale:

Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.

Choice C rationale:

Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.

Choice D rationale:

Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.

A. Swaddle the newborn with his legs extended. B. Schedule larger volume feedings at less frequent intervals. C. Maintain eye contact with the newborn during feedings. D. Plan care to minimize handling of the newborn.

Correct Answer is D

Explanation

Choice A rationale:
Swaddling the newborn with his legs extended is not the appropriate action for a newborn with neonatal abstinence syndrome (NAS). NAS occurs when a baby is born dependent on drugs, usually because the mother used opioids during pregnancy. Swaddling may provide some comfort, but extending the legs could increase discomfort and agitation.

Choice B rationale:
Scheduling larger volume feedings at less frequent intervals is not the correct approach for a newborn with NAS. These infants often have feeding difficulties and may require smaller, more frequent feedings to reduce the risk of aspiration.

Choice C rationale:
Maintaining eye contact with the newborn during feedings may not be well-tolerated by a baby with NAS. They can be irritable and easily overstimulated, and eye contact during feeding may exacerbate their agitation.

Choice D rationale:
Planning care to minimize handling of the newborn is the most appropriate action for a baby with NAS. These infants are sensitive to stimuli and can become agitated easily, so minimizing unnecessary handling helps reduce their distress.

The correct answer is D. Plan care to minimize handling of the newborn.

Here's why:

Swaddling with legs extended: This is not recommended as it can be uncomfortable for the newborn and may exacerbate withdrawal symptoms.
Larger volume feedings at less frequent intervals: This can be difficult for newborns with NAS due to their increased metabolic rate and may lead to overfeeding.
Maintaining eye contact during feedings: While this is important for bonding, it can be overwhelming for newborns with NAS, who often prefer a calm environment.

Minimizing handling is a key intervention in caring for newborns with NAS. Excessive handling can trigger withdrawal symptoms and make the newborn more irritable. Instead, focus on gentle, soothing techniques like swaddling with arms tucked in, rocking, and providing a quiet, dimly lit environment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

A nurse is performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following conditions?

A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client?

A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes mellitus. Which of the following findings should the nurse report to the provider?

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching?