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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
The nurse should first address the client’s calf findings followed by their stress about discharge.
Rationale for correct answers
Calf findings must be addressed first due to the risk of deep vein thrombosis (DVT), which is a known complication of cesarean delivery and postpartum immobility. The presence of unilateral calf edema (3 cm greater than the right) and tenderness, combined with an elevated D-dimer, strongly suggests a thrombotic process requiring urgent evaluation. If DVT is confirmed, anticoagulation therapy should be initiated promptly to prevent progression to pulmonary embolism.
Stress about discharge should be the second priority, as emotional concerns can affect adherence to postpartum care instructions. Addressing anxiety about recovery, follow-up visits, and newborn care can improve the client’s overall well-being and readiness for discharge.
Rationale for incorrect Response 1 options
- Breast engorgement: Although uncomfortable, this is a transient issue that can be managed with cold compresses and supportive bras. It does not pose an immediate health risk.
- Constipation: Postpartum bowel irregularities are expected after cesarean delivery; stool softeners and hydration can alleviate symptoms without urgency.
- Surgical incision pain: Rated only 2/10, indicating mild pain that does not require immediate intervention beyond routine analgesia.
Correct Answer is C
Explanation
Choice A rationale
While blood pressure can increase during the second trimester due to changes in the maternal cardiovascular system, it doesn't typically increase *early* in the second trimester. Physiologic changes usually lead to a slight decrease in blood pressure during the first and early second trimester before gradually returning to pre-pregnancy levels or potentially increasing later.
Choice B rationale
While multiparous women can develop gestational hypertension or preeclampsia, having had "several pregnancies" in the past does not inherently increase the risk of high blood pressure at 14 weeks gestation in the current pregnancy, especially if previous pregnancies were normotensive. Risk factors like age, pre-existing conditions, and family history are more significant.
Choice C rationale
Advanced maternal age, generally considered 35 years or older, is a known risk factor for developing gestational hypertension and preeclampsia during pregnancy. Physiological changes associated with aging can affect vascular function and increase susceptibility to hypertensive disorders.
Choice D rationale
While addressing the client's feelings is important for therapeutic communication, it avoids answering her direct question about why her blood pressure is being taken. The nurse has a responsibility to provide accurate information regarding routine assessments during pregnancy.
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