A nurse is reviewing the results of a nonstress test (NST) for a client who is at 32 weeks of gestation and has diabetes mellitus.
The nurse notes 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.
How should the nurse interpret this result?
Reactive
Nonreactive
Unsatisfactory
Equivocal
The Correct Answer is A
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.
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 C
Explanation
The nurse should instruct the client to brush her nipple with her palm for 2 minutes.
This will stimulate the release of oxytocin and cause uterine contractions.The fetal heart rate (FHR) will be monitored for any signs of fetal distress, such as decelerations.
Choice A is wrong because fasting is not required for a CST.Fasting may be necessary for other tests that involve anesthesia or sedation.
Choice B is wrong because drinking orange juice will not induce contractions.Orange juice may be given to increase fetal activity before a nonstress test (NST), which measures the FHR response to fetal movement.
Choice D is wrong because lying on the back can compress the inferior vena cava and reduce blood flow to the uterus and the fetus.The client should lie on her side during the test to prevent supine hypotension syndrome.
Normal ranges for FHR are 110 to 160 beats per minute, with moderate variability and no decelerations.Normal ranges for uterine contractions are less than five in a 10-minute period, lasting less than 90 seconds each.
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