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 B
A. An amniotic fluid index of 1 cm is abnormally low (oligohydramnios) and indicates potential fetal compromise, so this finding does not reflect fetal well-being.
B. Fetal limb movements are an important indicator of fetal activity and neurological function. Observing four or more discrete limb movements in 30 minutes meets one of the criteria for a reassuring biophysical profile, suggesting the fetus is active and neurologically intact.
C. A nonreactive nonstress test indicates the fetus is not showing adequate heart rate accelerations in response to movement, which can signal potential hypoxia or fetal compromise.
D. Sustained fetal breathing movements of 20 seconds in 30 minutes are desirable, but the minimum standard for the BPP is usually one or more episodes of 30 seconds within 30 minutes; 20 seconds alone may not meet the threshold, making limb movements a more reliable indicator in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreasing IV infusion rate does not relieve umbilical cord prolapse.
B. Placing the client in a knee-chest position helps relieve pressure on the prolapsed umbilical cord, improving fetal oxygenation until delivery.
C. Instructing the client to push can worsen cord compression and is contraindicated.
D. The nurse should not attempt to replace the umbilical cord into the cervix; this is a sterile procedure typically performed by the provider.
Correct Answer is D
Explanation
A. Fetal fibronectin testing is used to assess risk for preterm labor, not to confirm rupture of membranes.
B. Amniocentesis for fetal lung maturity is generally not needed at 37 weeks or later.
C. Urinalysis is for urinary tract issues, not for detecting amniotic fluid.
D. Nitrazine testing helps determine if vaginal fluid is amniotic fluid by assessing pH, aiding in diagnosing rupture of membranes.
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