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A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation.The results of the test indicate a negative CST.
Which of the following actions should the nurse take?

A.

Repeat the CST in 20 min.

B.

Administer an IV fluid bolus.

C.

Prepare the client for cesarean birth.

D.

Allow the labor to progress naturally.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Repeating the CST isn't necessary with a negative result, which indicates no significant uterine contractions affecting the fetus.

Choice B rationale

Administering an IV fluid bolus is not warranted by a negative CST result.

Choice C rationale

Preparing for a cesarean birth isn't necessary since a negative CST indicates no immediate fetal distress.

Choice D rationale

A negative CST indicates that there are no late decelerations, so the nurse should allow the labor to progress naturally.


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Related Questions

Correct Answer is A

Explanation

The nurse should identify that contractions occurring every 5 minutes require follow-up for several reasons:

  1. Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.
  2. Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.
  3. Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.
  4. Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

Preterm Labor

Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:

  • Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
  • Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
  • Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
  • Low backache: The client reports cramping and low back pain.

Preterm Prelabor Rupture of Membranes (PPROM)

PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:

  • Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.

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