A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation.
Which of the following findings should indicate to the nurse the need for further diagnostic testing?
An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.
No late decelerations noted with three uterine contractions of 60 seconds in
duration within a 10-min testing period.
Irregular contractions of 10 to 20 seconds in duration that are not felt by the
client.
The Correct Answer is C
A nurse assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation should indicate the need for further diagnostic testing if there are no late decelerations noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
Choice A is incorrect because an increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal result.
Choice B is incorrect because irregular contractions of 10 to 20 seconds in duration that are not felt by the client do not indicate the need for further diagnostic testing.
Choice D is incorrect because three fetal movements perceived by the client in a 20-min testing period do not indicate the need for further diagnostic testing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A nuchal cord occurs when the umbilical cord wraps around the fetal neck completely or for 360 degrees.
In some cases, a tight nuchal cord can cause conjunctival hemorrhage and petechiae.
Choice B) is not correct because erythema toxicum is a common rash seen in newborns and is not related to a nuchal cord.
Choice C) is not correct because periauricular papillomas are benign skin growths near the ear and are not related to a nuchal cord.
Choice D) is not correct because telangiectatic nevi, also known as stork bites or salmon patches, are common birthmarks seen in newborns and are not related to a nuchal cord.
Correct Answer is C
Explanation
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
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