A nurse is assisting with a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "What are you looking for during this test?" Which of the following responses should the nurse make?
"We are looking for increases in fetal heart rate of 15/min for at least 15 seconds. This means the baby is doing well."
"We will draw blood to evaluate the baby's risk of genetic problems."
"I am looking at the ultrasound to see if the baby has any congenital anomalies."
"If the baby moves 5 times in 15 minutes, then the baby is healthy."
The Correct Answer is A
A. "We are looking for increases in fetal heart rate of 15/min for at least 15 seconds. This means the baby is doing well." – Correct; a reactive NST shows at least two accelerations of 15 bpm lasting at least 15 seconds within 20 minutes, indicating fetal well-being.
B. "We will draw blood to evaluate the baby's risk of genetic problems." – Incorrect; an NST does not involve blood work; genetic testing is done through amniocentesis or blood screening.
C. "I am looking at the ultrasound to see if the baby has any congenital anomalies." – Incorrect; an NST does not evaluate congenital anomalies; an ultrasound or amniocentesis would be used for that.
D. "If the baby moves 5 times in 15 minutes, then the baby is healthy." – Incorrect; fetal movement is assessed with kick counts, not an NST.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Passageway – Incorrect; the provider states she has a roomy pelvis, meaning the passageway is adequate.
B. Powers – Correct; contractions are infrequent (every 10 minutes), short (30-40 sec), and mild, which may not be strong enough to promote cervical dilation and descent of the fetus.
C. Psyche – Incorrect; the patient is calm and relaxed, which supports labor progression.
D. Passenger – Incorrect; the baby is in an optimal (ROA) position and at +1 station, indicating normal progression.
Correct Answer is B
Explanation
A. The contractions are regular – Incorrect; regular contractions occur throughout labor, not just in the second stage.
B. The cervix is fully dilated. – Correct; the second stage of labor begins when the cervix is completely dilated (10 cm), allowing for pushing and delivery.
C. The membranes have ruptured – Incorrect; rupture of membranes can occur at any stage of labor.
D. The provider has ruptured the membranes – Incorrect; artificial rupture (amniotomy) does not determine the start of the second stage.
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