A nurse is performing a nonstress test (NST) for a pregnant client at 36 weeks of gestation who reports decreased fetal movement.
The nurse observes that the fetal heart rate (FHR) baseline is 120 bpm with minimal variability and no accelerations in a 20-minute period.
What should the nurse do next?
Offer the client a snack or juice to stimulate fetal activity
Apply an acoustic stimulator to elicit fetal movement
Stop the test and notify the provider immediately
Extend the test for another 20 minutes
The Correct Answer is A
Offer the client a snack or juice to stimulate fetal activity.
A nonstress test (NST) is a pregnancy screening that measures fetal heart rate and reaction to movement. It is performed to make sure the fetus is healthy and getting enough oxygen. A reactive NST means that the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice in a 20-minute period. A nonreactive NST means that this criteria is not met.
Choice B is wrong because applying an acoustic stimulator to elicit fetal movement is not recommended as a routine practice and may cause fetal distress.
Choice C is wrong because stopping the test and notifying the provider immediately is not necessary unless there are signs of fetal compromise, such as severe variable or late decelerations, or a nonreassuring fetal heart rate pattern.
Choice D is wrong because extending the test for another 20 minutes may not change the result and may prolong the discomfort of the client. A nonreactive NST does not mean there is a problem, but it may require further testing, such as a biophysical profile or a contraction stress test.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A nonstress test (NST) is a non-invasive test used to evaluate a baby’s well-being by monitoring fetal heartbeat and movements.The equipment needed for this procedure includes a belt with two transducers and a paper strip or a computer screen.The belt with two transducers is used to measure the fetal heart rate and uterine contractions, while the paper strip or computer screen displays the results.
Choice A is wrong because a reclining chair or bed is not necessary for an NST.The test can be done while the pregnant person is seated comfortably in a chair or resting in a reclined position on a table.
Choice D is wrong because a button for the client to press is not required for an NST.The test does not depend on the client’s perception of fetal movement, but rather on the objective measurement of fetal heart rate and uterine activity.
Choice E is wrong because an acoustic stimulator is not part of the standard equipment for an NST.
An acoustic stimulator is a device that produces a loud noise to stimulate the fetus and elicit a heart rate response.It may be used in some cases when the NST results are nonreactive, but it is not routinely used.
Correct Answer is D
Explanation
The test will require me to lie on my back for the duration of the test.This statement indicates a need for further teaching because lying on the back can compress the inferior vena cava and reduce blood flow to the baby.The test can be done in a reclining chair or on an exam table with a wedge under one hip to avoid this problem.
Choice A is correct because the test will measure how the baby’s heart rate changes when he moves.In most healthy babies, the heart rate increases during movement.
Choice B is correct because the test will take at least 20 minutes, but it may take longer if the baby is not active or moving during that time period.
Choice C is correct because the test will involve placing two belts around the abdomen.One will measure the baby’s heartbeat and the other will record contractions.
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