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 patient should have a full bladder for a transabdominal US and an empty bladder for a transvaginal US.”1 This is because a full bladder helps to lift the uterus and improve the visibility of the pelvic organs in a transabdominal US, while an empty bladder prevents distortion of the image in a transvaginal US.
Choice B is wrong because tight-fitting clothing is not necessary and lying prone on an examination table is uncomfortable and may interfere with the insertion of the vaginal probe.
Choice C is wrong because loose-fitting clothing is not necessary and lying supine on an examination table may cause supine hypotension syndrome in pregnant women.
Choice D is wrong because loose-fitting clothing is not necessary and lying prone on an examination table is uncomfortable and may interfere with the insertion of the vaginal probe.
Correct Answer is A
Explanation
An equivocal CST indicates late decelerations of the FHR with less than 50% of contractions.
This means that the fetus may have some degree of hypoxia or distress, but not enough to warrant immediate delivery.
An equivocal CST may also result from hyperstimulation of the uterus, which can cause excessive contractions and reduce blood flow to the placenta.
Choice B is wrong because late decelerations of the FHR with at least 50% of contractions is a positive CST, which indicates a high risk of fetal death due to hypoxia and is a contraindication to labor.
Choice C is wrong because no late decelerations of the FHR during contractions is a negative CST, which indicates a good fetal wellbeing and tolerance of labor.
Choice D is wrong because variable decelerations of the FHR with or without contractions are not related to uterine activity and may indicate cord compression or other fetal problems.
Variable decelerations are not used to interpret CST results.
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