A nurse is preparing to perform a nonstress test (NST) for a client who is at 36 weeks of gestation and reports decreased fetal movement.
Which of the following actions should the nurse take first?
Apply conduction gel to the client’s abdomen.
Instruct the client to press a button when she feels fetal movement.
Explain the purpose, procedure, and possible outcomes of the test to the client.
Activate a vibroacoustic stimulation device to wake up the fetus.
The Correct Answer is C
Explain the purpose, procedure, and possible outcomes of the test to the client. This is because the nurse should always obtain informed consent from the client before performing any procedure, and provide education and reassurance about the test.
Choice A is wrong because applying conduction gel to the client’s abdomen is not the first action the nurse should take. The nurse should first explain the test and obtain consent from the client before applying any equipment.
Choice B is wrong because instructing the client to press a button when she feels fetal movement is part of the nonstress test procedure, but not the first action. The nurse should first educate the client about the test and its purpose.
Choice D is wrong because activating a vibroacoustic stimulation device to wake up the fetus is not necessary for a nonstress test. This device may be used if the fetal heart rate is nonreactive, but only after explaining the test and obtaining consent from the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“This test will evaluate your baby’s well-being by monitoring his or her movements.”
A nonstress test (NST) is a simple, noninvasive way of checking on your baby’s health.The test records your baby’s movement, heartbeat, and reaction to movement.It is done after 26 to 28 weeks of pregnancyto check the health and oxygen supply of the fetus.It is safe, painless, and non-invasive, and can be performed in a doctor’s office or a hospital.It usually takes 40 to 60 minutes.
Choice A is wrong because this test will not measure the amount of amniotic fluid around your baby.That is done by another test called an amniotic fluid index (AFI).
Choice B is wrong because this test will not check if your baby has any chromosomal abnormalities.That is done by other tests such as amniocentesis or chorionic villus sampling (CVS).
Choice C is wrong because this test will not assess how your baby’s heart rate responds to contractions.That is done by another test called a contraction stress test (CST).
Correct Answer is A
Explanation
Reactive.This means that the fetal heart rate (FHR) accelerates at least 10 beats/min for at least 10 seconds two or more times in a 30-minute period.This result shows that the baby is getting enough oxygen and is doing well.
Nonreactive.
This means that the FHR does not accelerate as expected during the test.This result does not necessarily mean that there is a problem, but it may indicate that the baby is not getting enough oxygen or is asleep.
If this happens, more tests may be needed.
Unsatisfactory.This means that the test results are unclear or incomplete due to technical problems or poor quality of the recording.
If this happens, the test may need to be repeated.
Equivocal.This means that the test results are uncertain or inconclusive due to factors such as preterm gestation, fetal sleep, maternal medications, or fetal anomalies.
If this happens, more tests may be needed.
Normal ranges for FHR are between 110 and 160 beats/min at rest and between 120 and 180 beats/min during movement.
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