A nurse is performing a non-stress test (NST) for a client who is 34 weeks pregnant and has pre-eclampsia.
Which of the following fetal heart rate patterns indicates a reactive test?
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period
No accelerations or decelerations in a 20-minute period
One acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period
Variable decelerations with normal variability in a 20-minute period
The Correct Answer is A
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period. This indicates a reactive test, which means that the fetus is well oxygenated and not in distress.
Choice B is wrong because no accelerations or decelerations in a 20-minute period indicate a non-reactive test, which may suggest fetal hypoxia or acidosis.
Choice C is wrong because one acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period is the criterion for a reactive test for gestational age less than 32 weeks, not 34 weeks.
Choice D is wrong because variable decelerations with normal variability in a 20-minute period indicate cord compression or fetal head compression, not a reactive test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor the client’s deep tendon reflexes hourly because magnesium sulfate can cause neuromuscular blockade and decreased reflexes.The nurse should keep calcium gluconate readily available because it is the antidote for magnesium toxicity.The nurse should maintain a urine output of at least 40 mL/hr because magnesium is excreted by the kidneys and low urine output can indicate renal impairment or fluid overload.The nurse should check the client’s blood pressure every 15 minutes because magnesium sulfate can cause hypotension and preeclampsia can cause hypertension.
Choice D is wrong because the medication should not be infused via a peripheral IV line, but rather through a central line or a large-bore IV catheter to prevent tissue damage.
Correct Answer is A
Explanation
This indicates that the client has respiratory depression, which is a sign of magnesium toxicity.Magnesium sulfate is given to prevent and treat seizures in clients with eclampsia, but it can also cause adverse effects such as hypotension, decreased urine output, absent or diminished reflexes, and cardiac arrest.
Choice B is wrong because urine output of 50 mL/hr is within the normal range and does not indicate magnesium toxicity.The nurse should monitor the client’s urine output closely and report any decrease below 30 mL/hr.
Choice C is wrong because serum magnesium level of 6 mg/dL is within the therapeutic range of 4 to 7 mg/dL for clients receiving magnesium sulfate.The nurse should monitor the client’s serum magnesium level regularly and report any increase above 8 mg/dL, which indicates toxicity.
Choice D is wrong because patellar reflex of 2+ is normal and does not indicate magnesium toxicity.The nurse should assess the client’s deep tendon reflexes frequently and report any decrease or absence of reflexes, which indicates toxicity.
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