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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.
Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.
Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.
Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.
Correct Answer is D
Explanation
The correct answer is **d. The newborn is beginning to cough**.
Choice A rationale:
An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.
Choice B rationale:
A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.
Choice C rationale:
A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.
Choice D rationale:
The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.