A nurse is performing an external nonstress test for a client who is at 41 weeks of gestation and has oligohydramnios.
The nurse notes that there are no accelerations in the fetal heart rate tracing after applying an acoustic stimulator to the maternal abdomen for several seconds.
Which of the following actions should the nurse take?
Repeat the acoustic stimulation after 1 minute
Document the finding as a nonreactive NST
Perform a contraction stress test (CST)
Notify the provider and prepare for delivery
The Correct Answer is D
Notify the provider and prepare for delivery. Oligohydramnios is a condition where the amniotic fluid volume is less than expected for gestational age and it is associated with maternal and fetal complications.
The nonstress test (NST) is a method of fetal surveillance that measures the fetal heart rate response to fetal movement. A reactive NST is defined as at least two accelerations of 15 beats per minute or more above the baseline, lasting 15 seconds or more, within a 20-minute period.
A nonreactive NST indicates fetal hypoxia or acidosis and requires further evaluation. An acoustic stimulator can be used to elicit fetal movement and accelerations, but it should not be repeated more than once in a 10-minute period.
Therefore, choice A is wrong because repeating the acoustic stimulation after 1 minute is too soon and may cause fetal distress.
Choice B is wrong because documenting the finding as a nonreactive NST is not enough to address the situation. Choice C is wrong because performing a contraction stress test (CST) is contraindicated in oligohydramnios because it may cause umbilical cord compression and fetal compromise.
The CST involves inducing uterine contractions with oxytocin or nipple stimulation and monitoring the fetal heart rate for signs of intolerance.
A negative CST means that there
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Correct Answer is A
Explanation
Prepare the client for an amnioinfusion.An amnioinfusion is a procedure that adds fluid to the uterus during labor to relieve cord compression and improve fetal condition.Variable decelerations on the fetal monitor tracing are a sign of cord compression and fetal distress.If repositioning and oxygen administration do not resolve the decelerations, an amnioinfusion may be indicated.
Choice B is wrong because applying an internal fetal scalp electrode does not address the cause of variable decelerations, which is cord compression.
An internal fetal scalp electrode is used to monitor the fetal heart rate more accurately, but it does not improve fetal oxygenation or prevent cord compression.
Choice C is wrong because administering IV fluid bolus to the client may help increase maternal blood volume and placental perfusion, but it does not directly increase amniotic fluid volume or relieve cord compression.
Choice D is wrong because discontinuing oxytocin infusion if present may reduce uterine contractions and decrease cord compression, but it may also prolong labor and increase the risk of infection or fetal compromise.Oxytocin infusion should only be discontinued if there are signs of uterine hyperstimulation or fetal intolerance.
Correct Answer is B
Explanation
Negative CST.A negative CST means that there are no late or significant variable decelerations of the fetal heart rate (FHR) during three uterine contractions in 10 minutes.
This indicates that the fetus is well oxygenated and can tolerate the stress of labor contractions.
Choice A is wrong because a positive CST means that there are late decelerations of the FHR with 50% or more of the contractions.
This suggests that the fetus is at risk of hypoxia and may need early delivery.
Choice C is wrong because an unsatisfactory CST means that there are fewer than three contractions in 10 minutes or the tracing is not interpretable.
This does not provide enough information to assess the fetal well-being.
Choice D is wrong because an equivocal CST means that there are either intermittent late decelerations or significant variable decelerations.
This indicates that the fetus may have some degree of compromise and may need further testing.
Normal ranges for FHR are 110 to 160 beats per minute, and for uterine contractions are 2 to 5 per 10 minutes.
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