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.
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Related Questions
Correct Answer is D
Explanation
Rationale for Choice A:
A pelvic exam is required if you want birth control pills. This response is not therapeutic because it dismisses the client's feelings and does not address her concerns. It focuses on the policy or requirement rather than the client's emotional needs. It could make the client feel like her anxiety is not justified or that she has no choice in the matter.
Rationale for Choice B:
Don't worry, I will stay in there with you for the exam. While this response may be intended to provide reassurance, it does not fully address the client's underlying concerns. It offers a solution without first exploring the specific reasons for the client's anxiety. It could also make the client feel dependent on the nurse's presence for comfort, rather than empowering her to manage her own anxiety.
Rationale for Choice C:
All you need to do is relax during the exam. This response is not therapeutic because it minimizes the client's feelings and suggests that she can simply control her anxiety by relaxing. It does not acknowledge the validity of her concerns or provide any guidance on how to manage those concerns. It could make the client feel like her anxiety is her fault or that she is not coping well.
Rationale for Choice D:
Tell me more about your concerns. This is the most therapeutic response because it encourages the client to express her feelings and concerns openly. It validates the client's experience and demonstrates active listening and empathy. It provides an opportunity for the nurse to gather more information about the specific reasons for the client's anxiety and to tailor interventions accordingly. It also empowers the client by allowing her to share her thoughts and take control of the conversation.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: The recommended weight gain for a woman with a normal BMI (18.5-24.9) during pregnancy is 25-35 pounds. This range ensures adequate nutrition for both the mother and the developing baby, supporting optimal fetal growth and maternal health.
Choice B rationale: A weight gain of 11-20 pounds is recommended for women with a high BMI (≥30) during pregnancy. This range helps minimize the risk of complications such as gestational diabetes and hypertension, but it is not applicable for a woman with a normal BMI.
Choice C rationale: While a healthy diet is crucial, specific weight gain guidelines are essential to ensure the health of both mother and baby. Weight gain recommendations are based on evidence to support optimal outcomes, making it important to follow them.
Choice D rationale: A weight gain of 15-25 pounds is recommended for women with an overweight BMI (25-29.9) during pregnancy. This range helps support fetal growth while minimizing the risk of complications, but it is not applicable for a woman with a normal BMI.
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