A nurse is reviewing the results of a biophysical profile for a client who is at 37 weeks of gestation.
Which of the following findings indicates fetal well-being?
Nonreactive nonstress test.
The fetus had four limb movements in 30 minutes.
The fetus had 20 seconds of sustained breathing movements in 30 minutes.
Amniotic fluid index of 1 cm.
The Correct Answer is B
Choice A rationale
A nonreactive nonstress test (NST), defined by having fewer than two accelerations of at least 15 beats per minute (BPM) above baseline, lasting at least 15 seconds, within a 20-minute window, indicates potential fetal compromise or sleep state, leading to a maximum score of 0 on this component, thus not indicating well-being.
Choice B rationale
The biophysical profile (BPP) scores fetal movement with a maximum of 2 points for three or more discrete body or limb movements within a 30-minute period. The finding of four limb movements clearly meets this criterion and earns the full 2 points, reflecting an intact central nervous system and adequate fetal oxygenation, which is a sign of fetal well-being.
Choice C rationale
The BPP criterion for fetal breathing movements requires at least one episode of sustained movements for 30 seconds within the 30-minute observation period to score 2 points. The finding of 20 seconds is insufficient to meet this 30-second threshold, resulting in a score of 0 points for this component and thus not indicating full well-being.
Choice D rationale
The amniotic fluid index (AFI) measures the sum of the deepest vertical pockets of amniotic fluid in the four quadrants of the uterus. An AFI of 1 cm is significantly below the normal range of 5 cm to 25 cm, indicating oligohydramnios (low fluid). This finding scores 0 points on the BPP and suggests potential chronic fetal compromise or renal issues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A pain rating of 3/10 indicates mild pain and is a expected finding following a vaginal birth with a third-degree laceration repair. Pain alone is not the primary indicator for catheterization unless it is severe enough to prevent voiding. The focus for catheterization is on signs of urinary retention and its consequences, like uterine atony.
Choice B rationale
Lochia rubra (bright red discharge, typically lasting 1-3 days) is the expected type of lochia 4 hours postpartum, and a moderate amount is normal. The characteristics of lochia are indicators of uterine involution and healing, but do not directly confirm the need for a catheterization due to inability to void.
Choice C rationale
Ecchymosis (bruising) and edema of the perineum are expected signs following a vaginal birth, especially with a laceration and repair. While swelling can sometimes contribute to difficulty voiding, it is an expected localized finding and not the most direct indicator that immediate straight catheterization is required to manage urinary retention.
Choice D rationale
A boggy (soft, not contracted) and deviated uterus is the most critical sign indicating a full or distended bladder preventing the uterus from contracting effectively. This distention leads to urinary retention and significantly increases the client's risk for postpartum hemorrhage. Immediate straight catheterization is necessary to empty the bladder and allow the uterus to firm up.
Correct Answer is C
Explanation
Choice A rationale
Acyclovir is an antiviral medication used primarily to treat herpes simplex virus (HSV) infections to prevent vertical transmission to the neonate. Group B Streptococcus (GBS) is a bacterium and is treated with antibiotics, specifically penicillin or ampicillin, administered intravenously during labor and delivery to prevent neonatal sepsis.
Choice B rationale
The Group B Streptococcus (GBS) culture is typically collected as a single screen between 36 weeks 0 days and 37 weeks 6 days of gestation from the lower vagina and perirectal area. This one-time positive result is sufficient to indicate the need for intrapartum antibiotic prophylaxis (IAP); repeat testing 24 hours later is not standard practice.
Choice C rationale
If the Group B Streptococcus (GBS) culture is positive, the client is considered colonized and requires intrapartum antibiotic prophylaxis (IAP), usually penicillin G, administered intravenously at the onset of labor or rupture of membranes. This reduces the risk of GBS transmission to the newborn, which can cause severe neonatal morbidity like sepsis or pneumonia.
Choice D rationale
The Group B Streptococcus (GBS) culture is a screening test obtained via a swab of the client's lower vagina and perirectal area, not a blood test. The GBS bacteria colonize these areas, and the swab is sent for culture and sensitivity to determine the need for prophylactic antibiotics during labor.
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