A nurse is observing fetal breathing movements on an ultrasound for a client who is undergoing a biophysical profile (BPP).
The nurse should document how many points for this variable if the fetus has at least one episode of breathing lasting for 20 seconds within a 30-minute period?
0 points.
1 point.
2 points.
3 points.
The Correct Answer is C
According to the ACOG guidelines on antepartum fetal surveillance, one of the components of the biophysical profile is fetal breathing movements, which are scored as 2 points if there is one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes.
Choice A is wrong because 0 points are given for absent or no breathing episode for ≥30 seconds within a 30 minute observation period.
Choice B is wrong because there is no 1 point score for this variable.
Choice D is wrong because there is no 3 point score for this variable.
The maximum score for each variable is 2 points.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Monitor fetal heart rate.
This is because cramping and vaginal bleeding after amniocentesis are signs of possible complications such as miscarriage, preterm labor, or injury to the fetus.
Monitoring fetal heart rate can help assess the well-being of the fetus and detect any signs of distress.
Choice A is wrong because administering Rho(D) immunoglobulin is only necessary if the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause Rh sensitization.
This is not given routinely to all women who have amniocentesis.
Choice C is wrong because assessing maternal vital signs is not the first priority when there is a risk of fetal compromise.
Maternal vital signs can be affected by many factors and are not specific indicators of fetal health.
Choice D is wrong because obtaining an order for an ultrasound exam is not the first action to take.
An ultrasound exam can help confirm the diagnosis of complications such as placental abruption or fetal demise, but it requires time and equipment that might delay immediate intervention.
Monitoring fetal heart rate can be done quickly and easily at the bedside.
Correct Answer is B
Explanation
There are no known risks or complications for the pregnant person or the fetus.
Prenatal ultrasound is a safe and noninvasive procedure that uses sound waves to create images of the fetus and the placenta.
It does not use radiation or harm the fetal tissues.
Choice A is wrong because ultrasound does not cause harm to the fetus.
There is no evidence that ultrasound has any adverse effects on fetal development, growth, or health.
Choice C is wrong because pregnant individuals do not need to avoid ultrasound due to potential radiation exposure.
Ultrasound does not involve radiation, unlike x-rays or CT scans.
Choice D is wrong because ultrasound does not lead to miscarriage or preterm labor.
Ultrasound is not associated with any increased risk of pregnancy complications, such as miscarriage, preterm labor, or birth defects.
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