A pregnant client, who is 35 weeks along, comes in for weekly fetal heart monitoring.
After 20 minutes on the monitor, the fetal heart rate tracing shows three accelerations measuring 15 beats by 15 seconds.
How should the nurse report this finding to the provider?
Positive contraction stress test (CST).
Reactive nonstress test (NST).
Negative contraction stress test (CST).
Non-reactive nonstress test (NST).
The Correct Answer is B
Choice A rationale:
A positive contraction stress test (CST) indicates a potential problem with the fetal heart's response to uterine contractions, not spontaneous accelerations.
It's not consistent with the findings in this scenario.
Choice C rationale:
A negative CST would show no late decelerations in response to contractions, but it's not relevant here because contractions weren't induced.
Choice D rationale:
A non-reactive NST lacks the required accelerations, which are present in this case.
Choice B rationale:
Definition of reactive NST: A reactive NST is a reassuring fetal heart test that demonstrates a healthy fetal heart rate response to fetal movement. It's characterized by two or more fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting at least 15 seconds within a 20-minute period.
Significance of the findings: The presence of three accelerations measuring 15 bpm by 15 seconds within 20 minutes meets the criteria for a reactive NST. This suggests that the fetal nervous system is functioning well and responding appropriately to stimuli, indicating a healthy fetal heart rate pattern.
Nurse's reporting: The nurse should accurately report this finding to the provider as a "reactive nonstress test (NST)." This information is crucial for clinical decision-making regarding the ongoing management of the pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Visceral pain arises from the internal organs and is often described as dull, aching, cramping, or squeezing. During the first stage of labor, the uterus contracts forcefully to dilate the cervix and move the baby down the birth canal. This stretching and pressure on the uterus, cervix, and other pelvic organs stimulate pain receptors, resulting in visceral pain. This pain is typically located in the lower abdomen, back, and groin.
Key points about visceral pain in the first stage of labor:
It's often described as dull, aching, cramping, or squeezing.
It's caused by the stretching and pressure on the uterus, cervix, and other pelvic organs.
It's typically located in the lower abdomen, back, and groin.
It can be intermittent or continuous.
It can vary in intensity from mild to severe.
It's often accompanied by other symptoms such as nausea, vomiting, sweating, and anxiety.
Choice B rationale:
Referred pain is pain that is felt in a different location from the source of the pain. It's not typically associated with the first stage of labor.
Choice C rationale:
Somatic pain arises from the skin, muscles, bones, and joints. It's often described as sharp, stabbing, burning, or throbbing. The somatic pain of the second stage of labor is caused by the stretching and distension of the perineum and vagina as the baby descends. It's typically located in the lower back, buttocks, and thighs.
Choice D rationale:
Pain during the third stage of labor is typically mild compared to the first and second stages. It's caused by the contractions of the uterus as it expels the placenta. It's usually located in the lower abdomen and may be accompanied by a feeling of pressure or fullness.
Correct Answer is C
Explanation
Choice A rationale:
This statement suggests that the patient has some awareness of infertility treatments, but it does not necessarily indicate a full understanding of infertility itself.
It's important to consider that a few months of trying to conceive may not be indicative of infertility, as it can take up to a year for healthy couples to achieve pregnancy.
Jumping to fertility treatments without a proper evaluation could lead to unnecessary interventions and potential financial and emotional burdens.
Choice B rationale:
This statement is incorrect. Male factor infertility is a common cause of difficulty conceiving, accounting for about 40% of infertility cases.
It's essential to evaluate both partners when assessing fertility issues.
Choice C rationale:
This statement demonstrates the patient's understanding of the relationship between age and fertility.
Female fertility gradually declines with age, especially after the age of 35, due to a decrease in the number and quality of eggs.
This awareness indicates that the patient is realistic about her chances of conceiving and is prepared to seek appropriate help if needed.
Choice D rationale:
While family history can play a role in infertility, it's not a guarantee that someone will experience the same issues as their relatives.
Each case is unique, and multiple factors can contribute to infertility, including genetics, lifestyle, medical conditions, and environmental factors.
It's important to undergo a thorough evaluation to determine the specific causes of infertility in each individual.
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