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","E"]
Explanation
A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.
Correct Answer is C
Explanation
A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.
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