A nurse is performing a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "what are you looking for during this test?" Which of the following responses should the nurse make?

"We are looking for increases in fetal heart rate of 15 beats per minute for at least 15 seconds.

"We will draw blood to evaluate the baby's risk of genetic problems.”.

"If the baby moves 5 times in 15 minutes, then the baby is healthy.”.

"I am looking at the ultrasound to see if the baby has any congenital anomalies.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.

Choice B rationale

Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.

Choice C rationale

While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.

Choice D rationale

Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.

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Correct Answer is C

Explanation

Choice A rationale

Increasing ambulation is generally encouraged in the postpartum period to prevent complications like thrombophlebitis, but it does not address the potential cause of foul-smelling lochia. Foul odor is a key indicator of infection, and ambulation will not resolve an existing infection.

Choice B rationale

Increasing oral fluids is important for hydration in the postpartum period, but it will not directly address a foul-smelling odor in the lochia. While adequate hydration supports overall healing, it does not treat an infection. A foul odor strongly suggests a localized infectious process in the uterus.

Choice C rationale

Lochia that is red (rubra) is normal in the first few days postpartum. However, a foul-smelling odor is an abnormal finding and a significant indicator of a potential uterine infection, also known as endometritis or puerperal infection. Further assessment and intervention are required to identify and treat the infection.

Choice D rationale

Normal lochia progresses from rubra (red) to serosa (pinkish-brown) to alba (yellowish-white) over several weeks postpartum. Normal lochia should have a fleshy, not foul, odor. A foul smell is an abnormal finding that suggests an infectious process within the uterus and requires prompt attention.

A. Postpartum blues. B. Postpartum depression (PPD). C. Postpartum delirium. D. Attachment difficulty.

Correct Answer is A

Explanation

Choice A rationale

Postpartum blues are characterized by labile mood, tearfulness, anxiety, and irritability that typically peak around the third to fifth postpartum day and resolve within two weeks. These feelings are often attributed to hormonal shifts, psychological adjustments, and fatigue experienced after childbirth. The woman's statement of feeling "let down" and crying for no reason, occurring on the fourth postpartum day, aligns with the typical presentation of postpartum blues.

Choice B rationale

Postpartum depression (PPD) involves more intense and persistent symptoms than postpartum blues, including depressed mood, loss of interest or pleasure, changes in appetite and sleep, fatigue, feelings of worthlessness or guilt, and difficulty concentrating. These symptoms typically last longer than two weeks and interfere with daily functioning. The woman's statement alone does not provide enough information to diagnose PPD.

Choice C rationale

Postpartum delirium is a rare but serious psychiatric emergency characterized by rapid onset of confusion, disorientation, hallucinations, delusions, and agitation. It typically occurs within the first few days postpartum. The woman's description of her feelings does not suggest the presence of delirium.

Choice D rationale

Attachment difficulty refers to challenges in forming a secure emotional bond between the mother and her infant. While the woman expresses loving her son, her emotional state of feeling "let down" and crying is not a direct indicator of attachment difficulties, which manifest as a lack of engagement or negative interactions with the baby.

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A nurse is performing a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "what are you looking for during this test?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the lochia on a 1-day postpartum patient.The nurse notes that the lochia is red and has a foul-smelling odor.The nurse determines that this assessment finding:

Correct Answer is C

Explanation

During a telephone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, "I don't know what's wrong.I love my son, but I feel so let down.I seem to cry for no reason!" Which condition might this new mother be experiencing?

Correct Answer is A

Explanation

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