What is considered a reactive nonstress test (NST)?

A decrease in fetal heart rate during monitoring

The presence of at least two fetal heart rate accelerations during 20 minutes of monitoring

A rise in fetal heart rate of at least 15/min from baseline lasting for at least 15 seconds

The absence of fetal heart rate accelerations during monitoring

Answer and Explanation

The Correct Answer is B

A. A decrease in fetal heart rate during monitoring: A decrease in fetal heart rate (deceleration) is not a reassuring sign and suggests fetal distress, which is not considered reactive.

B. The presence of at least two fetal heart rate accelerations during 20 minutes of monitoring: A reactive NST is defined as at least two fetal heart rate accelerations of 15 beats per minute lasting at least 15 seconds within a 20-minute period, indicating fetal well-being.

C. A rise in fetal heart rate of at least 15/min from baseline lasting for at least 15 seconds: While this is part of the criteria for determining accelerations, the key aspect of a reactive NST is the presence of at least two such accelerations within a 20-minute period.

D. The absence of fetal heart rate accelerations during monitoring: The absence of accelerations in a 40-minute period is classified as a nonreactive NST, which may indicate fetal hypoxia or other concerns requiring further evaluation.

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Correct Answer is A

Explanation

A. Urinary output 40 mL in 2 hr: Oliguria (urine output < 30 mL/hr) is a sign of magnesium toxicity, which can lead to respiratory depression, loss of reflexes, and cardiac arrest. The kidneys excrete magnesium, and impaired renal function increases toxicity risk. This finding requires immediate action.

B. Fetal heart rate 158/min: A fetal heart rate of 158 bpm is within the normal range (110-160 bpm) and is not a priority concern.

C. Reflexes +2: A +2 reflex response is normal. In magnesium toxicity, reflexes become diminished or absent (+1 or 0), indicating neuromuscular depression.

D. Respirations 16/min: While respiratory depression is a concern with magnesium sulfate, a respiratory rate of 16 breaths/min is within normal limits (12-20 bpm) and does not require immediate intervention. However, monitoring is still necessary.

A. Increase the rate of maintenance IV infusion. B. Administer oxygen using a nonrebreather mask. C. Elevate the client's legs. D. Place the client in the lateral position.

Correct Answer is D

Explanation

A. Increase the rate of maintenance IV infusion. Increasing IV fluids may help improve placental perfusion, but it is not the first action. Repositioning the client takes priority to improve blood flow before considering IV adjustments.

B. Administer oxygen using a nonrebreather mask. Oxygen is beneficial in improving fetal oxygenation, but positioning the client laterally should be done first to optimize blood flow before oxygen administration.

C. Elevate the client’s legs. Elevating the legs may be helpful in cases of hypotension, but this scenario describes late decelerations, which are related to uteroplacental insufficiency.

D. Place the client in the lateral position. Late decelerations are caused by uteroplacental insufficiency, leading to fetal hypoxia. The first action is to reposition the client to the lateral position, which improves blood flow to the placenta and enhances fetal oxygenation.

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What is considered a reactive nonstress test (NST)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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What is considered a reactive nonstress test (NST)?

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