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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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Nesting – Correct; nesting instinct refers to a surge of energy in late pregnancy, leading the mother to prepare for the baby.

B. Bloody show – Incorrect; bloody show refers to mucus mixed with blood, a sign of cervical dilation.

C. Lightening – Incorrect; lightening refers to the baby dropping into the pelvis, making breathing easier but increasing pressure on the bladder.

D. Effacement – Incorrect; effacement is the thinning of the cervix, an essential part of labor but not related to nesting.

A. Quickening B. Amenorrhea C. Ballottement D. Increased urination E. Positive pregnancy test via blood work

Correct Answer is ["C","E"]

Explanation

A. Quickening – Incorrect; quickening (fetal movement) is a presumptive sign of pregnancy.
B. Amenorrhea – Incorrect; absence of menstruation is a presumptive sign of pregnancy.
C. Ballottement – Correct; ballottement is a probable sign, not a presumptive sign, as it is detected by a healthcare provider.
D. Increased urination – Incorrect; frequent urination is a presumptive sign of pregnancy.
E. Positive pregnancy test via blood work – Correct; a positive pregnancy test is a probable sign, not a presumptive one.

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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?

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