A pregnant woman comes in for her weekly fetal heart monitoring.
She is 35 weeks’ gestation.
After 20 minutes on the monitor, the fetal heart rate tracing shows 3 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 A
Choice A rationale:
A positive contraction stress test (CST) indicates that the fetal heart rate decelerates late in response to uterine contractions, suggesting potential uteroplacental insufficiency. However, the scenario does not describe a CST being performed, as it does not mention any assessment of uterine contractions or their relationship to fetal heart rate changes.
Choice C rationale:
A negative contraction stress test (CST) would demonstrate no late decelerations in response to contractions, suggesting adequate placental function. However, as mentioned earlier, a CST is not the test being performed in this scenario.
Choice D rationale:
A non-reactive nonstress test (NST) means that there were not enough fetal heart rate accelerations (at least 2, each lasting at least 15 seconds and peaking at least 15 beats above baseline) within a 20-minute period. This finding sometimes warrants further evaluation of fetal well-being. However, the scenario clearly states that 3 accelerations meeting the criteria for reactivity were observed.
Choice B rationale:
A reactive nonstress test (NST) is considered reassuring and indicates that the fetal heart rate is responding appropriately to fetal movement, suggesting that the fetus is likely healthy and well-oxygenated. The presence of 3 accelerations meeting the criteria for reactivity within a 20-minute period is the hallmark of a reactive NST.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A rationale:
Incorrect. Nitrous oxide can be used during any stage of labor, not just the second stage. It is often used during the first stage to help manage early labor pain.
Evidence: Studies have shown that nitrous oxide is effective for pain relief during both the first and second stages of labor.
Additional information: The timing of nitrous oxide administration is typically based on the individual's preferences and needs. Some people prefer to use it as soon as labor begins, while others wait until contractions become more intense.
Choice B rationale:
Incorrect. Nitrous oxide is not a prelude to cesarean birth. It is a method of pain relief that can be used during vaginal or cesarean birth.
Evidence: Cesarean birth is a major surgical procedure that is typically performed under regional or general anesthesia. Nitrous oxide is not a type of anesthesia that would be used for this purpose.
Additional information: Cesarean birth is usually only performed when there is a medical reason why a vaginal birth is not possible or safe.
Choice C rationale:
Incorrect. Nitrous oxide is still a commonly used method of pain relief during labor. It is safe and effective, and it has a good safety profile.
Evidence: Nitrous oxide is one of the most widely used methods of pain relief during labor in many countries around the world.
Additional information: The use of nitrous oxide during labor has been increasing in recent years, as more people have become aware of its benefits.
Choice D rationale:
Correct. The procedure described in the question is an application of nitrous oxide. Nitrous oxide is a colorless, odorless gas that has analgesic and anxiolytic properties. It is often used during labor to help manage pain and anxiety.
Evidence: Nitrous oxide is a well-established method of pain relief during labor. It has been used for this purpose for over a century.
Additional information: Nitrous oxide is a safe and effective option for pain relief during labor. It is easy to administer and has few side effects.
Correct Answer is ["B","C","E","F"]
Explanation
The correct answers are B, C, E, and F.
Rationale for each choice:
- Albuterol
Mechanism of action: Albuterol is a beta-2 agonist that stimulates beta-2 receptors in the cell membranes of skeletal muscle, liver, and adipose tissue. This stimulation causes an increase in intracellular cyclic AMP (cAMP), which activates protein kinase A (PKA). PKA then phosphorylates a number of proteins, including the sodium-potassium ATPase pump. This pump is responsible for transporting potassium ions into cells and out of the bloodstream. By increasing the activity of this pump, albuterol can help to lower serum potassium levels.
Onset of action: Albuterol has a rapid onset of action, typically within 30 minutes.
Duration of action: The duration of action of albuterol is relatively short, usually 4-6 hours.
Dosage: The dosage of albuterol for hyperkalemia is typically 10-20 mg nebulized every 4-6 hours.
Additional considerations: Albuterol can cause tachycardia and tremors. It should be used cautiously in patients with heart disease or hyperthyroidism.
- Kayexalate
Mechanism of action: Kayexalate is a cation exchange resin that binds to potassium ions in the gastrointestinal tract. This prevents the potassium from being absorbed into the bloodstream.
Onset of action: Kayexalate has a relatively slow onset of action, usually 1-2 hours.
Duration of action: The duration of action of Kayexalate is relatively long, usually 4-6 hours.
Dosage: The dosage of Kayexalate for hyperkalemia is typically 15-30 grams orally or rectally every 6 hours.
Additional considerations: Kayexalate can cause constipation and hypocalcemia. It should be used cautiously in patients with bowel obstruction or kidney disease.
- Insulin & dextrose
Mechanism of action: Insulin promotes the movement of potassium into cells, thus lowering serum potassium levels. Dextrose is given along with insulin to prevent hypoglycemia.
Onset of action: Insulin has a rapid onset of action, typically within 30 minutes.
Duration of action: The duration of action of insulin is relatively short, usually 4-6 hours.
Dosage: The dosage of insulin for hyperkalemia is typically 10 units of regular insulin IV push, followed by an infusion of 5-10 units per hour. The dosage of dextrose is typically 50 grams IV push, followed by an infusion of 10% dextrose at 100 mL/hour.
Additional considerations: Insulin can cause hypoglycemia. It should be used cautiously in patients with diabetes mellitus.
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