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?
Amniotic fluid index of 1 cm
The fetus had four limb movements in 30 min.
Nonreactive nonstress test
The fetus had 20 seconds of sustained breathing movements in 30 min
The Correct Answer is D
A. An amniotic fluid index (AFI) less than 5 cm indicates oligohydramnios and potential fetal compromise.
B. Fetal limb movements fewer than 3 in 30 minutes may be concerning; however, 4 movements suggest some activity but must be assessed with other parameters.
C. A nonreactive nonstress test suggests fetal distress or lack of fetal well-being.
D. Sustained fetal breathing movements of at least 20 seconds in 30 minutes indicate good fetal neurologic function and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","F"]
Explanation
A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.
B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.
C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.
D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.
E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.
F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.
G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.
Correct Answer is D
Explanation
A. Effleurage (light abdominal stroking) is most helpful during early labor, not typically during pushing.
B. Counterpressure is usually applied to the lower back, not the upper abdomen, to relieve back labor pain.
C. The temperature for hydrotherapy (water immersion) is typically maintained around 37–38°C to ensure comfort and safety.
D. Using a TENS (transcutaneous electrical nerve stimulation) unit on the lower back or abdomen can help decrease labor pain by stimulating nerves and providing pain relief.
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