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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A:
The umbilicus is typically the location of the fundus at around 20 weeks of gestation, not 22 weeks.
If the fundus is at the umbilicus at 22 weeks, it could indicate that the fetus is not growing at the expected rate. This would warrant further investigation, such as an ultrasound, to assess fetal growth and development.
Choice C:
3 cm below the umbilicus is too low for a 22-week gestation.
This would suggest that the fetus is smaller than expected for the gestational age.
Possible causes of this include incorrect dating of the pregnancy, fetal growth restriction, or oligohydramnios (low amniotic fluid).
Choice D:
5 cm above the umbilicus is too high for a 22-week gestation.
This could indicate that the woman is carrying multiples, has polyhydramnios (excess amniotic fluid), or that the fetus is larger than expected for the gestational age (macrosomia).
Importance of Fundal Height Measurement:
Fundal height measurement is a simple, non-invasive way to assess fetal growth and development during pregnancy. It is typically measured at each prenatal appointment, starting at around 20 weeks of gestation.
By tracking the fundal height over time, healthcare providers can identify potential problems with fetal growth and make necessary interventions.
Correct Answer is B
Explanation
Choice A:
Applying ice to the perineal area is not a recommended intervention for suspected placenta previa. While ice can help reduce swelling and pain in some cases, it does not address the underlying concern of potential placental bleeding.
Focusing on external monitoring for fetal well-being and avoiding any actions that could disrupt the placenta are the priorities in this situation.
Choice C:
Completing a vaginal exam is contraindicated in suspected placenta previa. Inserting fingers into the vagina can disrupt the placenta and potentially cause heavy bleeding, increasing the risk of preterm labor, fetal distress, or maternal hemorrhage. Non-invasive assessment methods are crucial to protect the placenta and prevent complications.
Choice D:
Performing a rectal exam is also not indicated for suspected placenta previa. It does not provide information about the placental position and could potentially stimulate contractions, which are undesirable in this situation.
External fetal monitoring is a safer and more informative approach.
Choice B:
Applying an external fetal monitor is the most appropriate action for a nurse caring for a client with suspected placenta previa. It allows for continuous assessment of fetal heart rate and activity, which can help detect any signs of fetal distress or placental abruption.
It is a non-invasive method that does not carry the risks associated with vaginal or rectal exams.
Early identification of any fetal compromise can lead to prompt interventions to ensure the best possible outcomes for both mother and baby.
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