A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
Three fetal movements perceived by the client in a 20 min testing period
No late decelerations in the foetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
An increase in foetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to foetal movement within a 40-min testing period
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
The Correct Answer is A
A nonstress test measures fetal heart rate in response to fetal movement. A reactive nonstress test result is when there are at least two accelerations of the fetal heart rate within a 20-minute period, each lasting at least 15 seconds and peaking at least 15 beats per minute above the baseline. If there are fewer than two accelerations within a 20-minute period, further diagnostic testing may be needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Absent deep tendon reflexes are a sign of magnesium toxicity, which can occur with high levels of magnesium in the bloodstream. This can be a serious complication that requires immediate atention from the provider.
Option A, a decrease in frequency of contractions, is actually a desired effect of magnesium sulfate in the management of preterm labor. It is not a cause for concern.
Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not necessarily related to the administration of magnesium sulfate. However, it should still be reported to the provider for appropriate management.
Option D, a urinary output of 35 mL/hr, is below the normal range but it may still be within an acceptable range for a client receiving magnesium sulfate. The provider should be notified if urinary output continues to decrease or if it falls below a certain threshold.
Correct Answer is C
Explanation
Choice A is incorrect because medroxyprogesterone injections are typically given every three months, not every eight weeks.
Choice B is incorrect; the client will receive only one shot at a time, not two.
Choice C is correct; clients are advised to increase their calcium intake while on medroxyprogesterone to help prevent bone density loss, which can be a side effect of the medication.
Choice D is incorrect; spotting is a common side effect of medroxyprogesterone, and clients are usually advised to continue the medication despite this unless advised otherwise by their healthcare provider.
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