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 A
Explanation
The baby’s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy.
This is a device that uses sound waves to create an image of the baby’s heart and measure its rate and rhythm.
Some possible explanations for the other choices are:
Choice B is wrong because the baby’s sex can not be determined by ultrasound at 8 weeks of pregnancy.
The external genitalia are not fully developed until around 14 to 16 weeks of pregnancy.
Even then, the accuracy of ultrasound depends on factors such as the position of the baby, the quality of the equipment, and the skill of the sonographer.
Choice C is wrong because the baby’s lungs are not fully mature by 24 weeks of pregnancy.
The lungs are one of the last organs to develop in the fetus and they continue to grow and mature until near term.
The production of surfactant, a substance that helps the lungs expand and prevent collapse, begins around 24 weeks but is not sufficient until around 34 to 36 weeks.
Choice D is wrong because the baby’s eyes do not open and close by 16 weeks of pregnancy.
The eyelids are fused together until around 26 to 28 weeks of pregnancy, when they start to open and close periodically.
The baby can also respond to light and dark stimuli around this time.
Correct Answer is A
Explanation
“I will have sensors placed on my abdomen to monitor the FHR and uterine contractions.” This statement indicates the client understands the test procedure of a CST, which is a test that triggers contractions and registers how the baby’s heart reacts.
The test is done by placing two sensor belts around the abdomen, one to measure the baby’s heartbeat and the other to measure contractions.
The client may receive oxytocin through an IV to induce contractions.
Choice B is wrong because the client does not need to fast for 24 hours before the test.
There is no evidence that fasting is required for a CST.
Choice C is wrong because the client will not be sedated during the test.
Sedation is not necessary for a CST and may interfere with the results.
Choice D is wrong because the client does not need to drink plenty of fluids before the test.
There is no evidence that drinking fluids is required for a CST.
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