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.

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Correct Answer is B

Explanation

The correct answer is choice B: Administer a bolus infusion of lactated Ringer’s.

Choice A rationale:

Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.

Choice B rationale:

Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.

Choice C rationale:

Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.

Choice D rationale:

Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.

A. Place the client in a Trendelenburg position. B. Assist the client to void. C. Administer oxygen to the client via face mask at 10 L/min. D. Give calcium gluconate to the client.

Correct Answer is C

Explanation

Choice A rationale:
Placing the client in a Trendelenburg position (head down and feet up) is not recommended after a convulsion in a pregnant client. It could potentially compromise blood flow to the brain and fetus. The priority after a convulsion is to ensure the client's airway and oxygenation.

Choice B rationale:
Assisting the client to void might be necessary during the course of care but is not the immediate action needed after a convulsion. The priority is to address airway and oxygenation needs.

Choice C rationale:
Administering oxygen to the client via face mask at 10 L/min is the correct action after the client experiences a convulsion. Eclampsia is a severe complication of preeclampsia, characterized by seizures. Providing oxygen ensures adequate oxygenation to the brain and vital organs during and after the convulsion.

Choice D rationale:
Giving calcium gluconate is not the appropriate action for eclampsia. Calcium gluconate is used to treat hyperkalemia and calcium channel blocker overdose. It does not address the underlying issue of eclampsia or prevent further convulsions. The immediate focus should be on managing the convulsions and ensuring the client's safety and well-being.

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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 caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

Correct Answer is C

Explanation

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