The nurse is reading the results of non-stress test (NST) strips completed that day. Which of the following strips meets the criteria for a reactive NST? Select one:

A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes.

A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes.

A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes.

A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes.

Answer and Explanation

The Correct Answer is B

Choice A Reason: A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. A non-reactive NST may suggest fetal hypoxia, distress, or sleep, but it does not necessarily indicate a problem. A non-reactive NST may require further testing or stimulation to elicit a reactive result.

Choice B Reason A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. This is because this strip meets the criteria for a reactive NST, which is a non-invasive test that evaluates fetal well- being and oxygenation by measuring the fetal heart rate response to fetal movements. A reactive NST is defined as having at least two accelerations of the fetal heart rate that are at least 15 beats per minute above the baseline and last for at least 15 seconds within a 20-minute period.

Choice C Reason: A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in amplitude, as they are only 5 beats per minute above the baseline, instead of at least 15 beats per minute.

Choice D Reason: A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in duration, as they last only for 10 seconds, instead of at least 15 seconds.

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Correct Answer is D

Explanation

Choice A Reason: "Your body is responding to the events of labor, just like after a tough workout." This is an inaccurate statement that does not explain the cause of the contractions or reassure the client.

Choice B Reason: "This could be a sign that your body is trying to get rid of retained placental fragments." This is an alarming statement that may scare the client and imply that something is wrong. Retained placental fragments are rare and usually cause heavy bleeding, fever, and infection.

Choice C Reason: "Let me check your vaginal discharge just to make sure everything is fine." This is an unnecessary statement that does not answer the client's question or provide any information.

Choice D Reason:"The baby's sucking releases oxytocin which causes your uterus to contract." This is a correct statement that explains the physiological mechanism of the contractions and reassures the client that they are normal and beneficial.

A. Possible Meconium Aspiration Syndrome (MAS). B. Possible polycythemia. C. Possible Transient Tachypnea of the Newborn (TTN). D. Possible Respiratory Distress Syndrome (RDS).

Correct Answer is D

Explanation

Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inﬂammation, and infection. MAS usually aﬀects term or post-term infants who experience fetal distress or hypoxia in utero.

Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.

Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.

Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung ﬂuid after birth. TTN causes rapid breathing, nasal ﬂaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.

Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal ﬂaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.

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The nurse is reading the results of non-stress test (NST) strips completed that day. Which of the following strips meets the criteria for a reactive NST? Select one:

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Naxlex Comprehensive Predictor Exams

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Explanation

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