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 C

Explanation

The correct answer is choice c. Heart rate 72/min.

Choice A rationale:

A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.

Choice B rationale:

A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.

Choice C rationale:

A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.

Choice D rationale:

A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).

A. Position the client in a knee-chest position. B. Administer a bolus infusion of lactated Ringer's. C. Give terbutaline subcutaneously. D. Apply oxygen via a nonrebreather face mask at 2 L/min.

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.

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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

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Explanation

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Correct Answer is B

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