When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.
This should be documented as:
Reactive Non-stress test.
Non-reactive Non-stress test.
Negative Non-stress test.
Positive Non-stress test.
The Correct Answer is A
Choice A rationale
A reactive non-stress test indicates fetal well-being. The criteria for a reactive NST in a fetus greater than 32 weeks gestation include two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline lasting for at least 15 seconds within a 20-minute period. The baseline fetal heart rate should be within the normal range of 110 to 160 beats per minute. This client's results meet these criteria.
Choice B rationale
A non-reactive non-stress test lacks the required number of fetal heart rate accelerations or the accelerations do not meet the amplitude or duration criteria within the specified time frame. This suggests the fetus may be experiencing some form of stress and requires further evaluation.
Choice C rationale
A negative non-stress test is not a standard term used to describe NST results. The test is categorized as either reactive (indicating fetal well-being) or non-reactive (suggesting potential fetal compromise).
Choice D rationale
A positive non-stress test is also not a standard term used for NST interpretation. A positive result in fetal monitoring typically refers to a contraction stress test where late decelerations are observed, indicating potential uteroplacental insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).
Choice B rationale
This option incorrectly states L as 2. The client has one living child from the previous pregnancy.
Choice C rationale
This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.
Choice D rationale
This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.
Correct Answer is D
Explanation
Choice A rationale
Assessing the patient's urine for protein and glucose is relevant for evaluating potential preeclampsia or gestational diabetes, but it does not directly address the immediate concern of decreased fetal movement. While these conditions can indirectly affect fetal well-being, the priority is to assess fetal status directly.
Choice B rationale
Preparing the patient for an abdominal ultrasound can provide information about fetal well-being and amniotic fluid volume, but it is not the immediate first-line intervention for a concerning decrease in fetal kick counts. Further assessment is needed before resorting to diagnostic procedures.
Choice C rationale
A kick count of 32 movements in 4 hours is below the generally accepted normal range. While definitions vary slightly, many healthcare providers consider fewer than 10 movements in 2 hours or a significant decrease from the patient's baseline to be concerning and warrant further investigation. Reassuring the patient without further assessment would be inappropriate.
Choice D rationale
A decrease in fetal movement can be a sign of fetal distress and requires prompt evaluation by a healthcare provider. Notifying the physician or midwife is the correct priority nursing intervention to initiate further assessment of fetal well-being, which may include a non-stress test (NST) or biophysical profile (BPP).
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