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. 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.
Correct Answer is D
Explanation
A. Encourage the client to nurse more frequently so her milk will come in. – Incorrect; milk production typically begins between days 2-5 postpartum, not 14 hours postpartum.
B. Report the client's temperature elevation. – Incorrect; a temperature of 37.7°C (100°F) is within normal postpartum range due to dehydration and hormonal shifts.
C. Increase IV fluids. – Incorrect; IV fluids are not needed unless dehydration is suspected.
D. Ask the client to empty her bladder. – Correct; a fundus deviated to the right suggests a full bladder, which can impede uterine involution and increase postpartum hemorrhage risk.
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