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?

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.

Choice A rationale:

Allowing parents to enter the nursery while wearing masks may be a preventive measure for some situations, but it is not a standard infection control procedure in a newborn nursery.

Choice B rationale:

Airborne precautions are not required for routine infection control in a newborn nursery. They are typically reserved for specific airborne-transmitted infections.

Choice C rationale:

Placing the newborn's foot on a sterile field during a heel stick is a procedure to maintain sterile technique but is not a general infection control instruction for the nursery.

Choice D rationale:

Placing newborn bassinets at least 3 feet apart is a crucial infection control measure in a newborn nursery. It helps prevent cross-contamination and the spread of infections among newborns. Proper spacing allows for better airflow and reduces the risk of contact transmission between infants.