A nurse caring for a client during a non-stress test (NST) notes fetal movement. Each deceleration lasts 30 seconds.
Which of the following results are in?
Negative test.
Positive test.
Reactive test.
Non-reactive deceleration of rising in the fetal heart rate during a period.
The Correct Answer is C
Choice A rationale:
A negative test implies a non-reactive NST, meaning the fetal heart rate (FHR) did not demonstrate the expected accelerations in response to fetal movements.
However, the scenario states that fetal movements were noted, and decelerations were observed. Decelerations, even lasting 30 seconds, are not consistent with a negative test.
Choice B rationale:
A positive test is not a standard term used in the context of NST results.
The term "positive" is more often associated with tests that identify a specific condition or abnormality.
NST results are typically classified as reactive or non-reactive, with further interpretation based on the presence or absence of decelerations and other FHR patterns.
Choice C rationale:
A reactive NST is the desired outcome, indicating a healthy fetal response to movement.
It requires two or more FHR accelerations of at least 15 beats per minute for a minimum of 15 seconds, each within a 20- minute period.
Although the decelerations lasting 30 seconds warrant further assessment, they do not negate the presence of the required accelerations, making the test reactive.
Choice D rationale:
"Non-reactive deceleration of rising in the fetal heart rate during a period" is not a standard NST result terminology.
It incorrectly combines elements of non-reactivity (lack of accelerations) with a description of decelerations, which are distinct FHR patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A:
Fetal heart tone location: In a frank breech presentation, the fetal buttocks are positioned downward and the legs are extended straight up toward the head, placing the fetal heart closer to the mother's upper abdomen. This results in fetal heart tones being heard above the umbilicus at midline.
Gestation period: At 9 weeks of gestation, the fetus is still small and has ample room to move within the uterus, making breech presentations more common. However, it's important to note that the ideal position for childbirth is cephalic, with the head down.
Other presentations:
Cephalic presentations typically have fetal heart tones below the umbilicus.
Transverse presentations usually have fetal heart tones laterally, off to one side of the abdomen.
Posterior presentations, while still head down, can have fetal heart tones that are difficult to locate or muffled due to the position of the fetal back against the mother's spine.
Choice B:
Fetal position: In a transverse presentation, the fetus is positioned horizontally across the uterus, with the head and buttocks on either side. This typically results in fetal heart tones being heard laterally, rather than above the umbilicus at midline.
Choice C:
Fetal position: In a cephalic presentation, the fetus is head down, with the buttocks near the fundus of the uterus. This usually results in fetal heart tones being heard below the umbilicus, rather than above it.
Choice D:
Fetal position: In a posterior presentation, the fetus is head down, but facing the mother's back. While this can sometimes make fetal heart tones difficult to locate, they are typically still heard below the umbilicus, rather than above it.
Correct Answer is B
Explanation
Choice A rationale:
Premature maturity is not a plausible cause of bleeding without contractions at 1 week of pregnancy. Premature maturity, or preterm labor, refers to labor that begins before 37 weeks of gestation. It is characterized by contractions and cervical changes, often accompanied by other symptoms such as lower back pain, pelvic pressure, or a change in vaginal discharge. At 1 week of pregnancy, the fetus is still in the very early stages of development, and premature labor is not possible.
Choice C rationale:
The location of the placenta can sometimes cause bleeding in pregnancy, but it is typically associated with later stages of gestation, such as the second or third trimester. Placental conditions like placenta previa, where the placenta lies low in the uterus and partially or completely covers the cervix, can lead to bleeding, but this is unlikely to occur at 1 week of pregnancy. Moreover, placenta previa is usually accompanied by pain or cramping, which is not present in the client's case.
Choice D rationale:
The frequency and duration of contractions are relevant in assessing labor progression, but they are not a primary cause of bleeding without contractions. Contractions are the rhythmic tightening and relaxing of the uterine muscles that help to dilate the cervix and move the baby through the birth canal. Bleeding without contractions at 1 week of pregnancy suggests a different underlying issue.
Choice B rationale:
Incompetency, also known as cervical insufficiency or cervical incompetence, is the most likely cause of bleeding without contractions at 1 week of pregnancy. It occurs when the cervix is weak and begins to open prematurely, even without the presence of contractions. This can lead to bleeding and potential miscarriage or preterm birth. The fact that the client can feel the baby moving does not rule out cervical insufficiency, as fetal movement can sometimes be felt as early as 13-16 weeks of pregnancy.
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