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A nurse is caring for a 28-year-old pregnant female client at 38 weeks gestation who arrived to the OB triage unit with complaints of decreased fetal movement.

Exhibits

Complete the following sentence using the list of options. The nurse assesses the NonStress Test (NST) and documents the results as

. The nurse contacts the provider and reports the NST results. The nurse anticipates an order for a .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

 

Based on the provided information, here is the completion of the sentence using the options:

The nurse assesses the Non-Stress Test (NST) and documents the results as Non-Reactive. The nurse contacts the provider and reports the NST results. The nurse anticipates an order for a Biophysical Profile.

A Non-Stress Test (NST) is used to monitor the fetal heart rate (FHR) and its response to fetal movements. A reactive NST indicates that there are accelerations in the FHR in response to fetal movements, which is a sign of fetal well-being. A non-reactive NST means that there are no accelerations in the FHR with fetal movements, suggesting that the fetus might not be as active or responding as expected.

In this case, the NST was non-reactive because there were no accelerations in the fetal heart rate. This can be a cause for concern, as it may indicate potential issues with the fetus that need further evaluation. Therefore, the nurse would document the NST as non-reactive and contact the provider for further assessment.

A Biophysical Profile (BPP) is often ordered after a non-reactive NST. The BPP is a more comprehensive test that includes an ultrasound to assess fetal movement, muscle tone, breathing movements, and amniotic fluid volume, in addition to another NST. This helps to provide a clearer picture of the fetus's well-being.


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Based on the provided information:

  • The client had a vacuum-assisted vaginal delivery with a heavy lochia and small clots noted.
  • A boggy fundus and the need for oxytocin infusion also indicate an increased risk for excessive bleeding.

Given these observations, the client is at the highest risk for developing Postpartum hemorrhage (Option A) due to Heavy lochia with small clots (Option C).

So, the completed sentence would be:

"The client is at highest risk for developing Postpartum hemorrhage due to Heavy lochia with small clots."

Correct Answer is ["A","B","C","D","G"]

Explanation

Choice A: Respiratory assessment

  • The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.

Choice B: Hemoglobin

  • The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.

Choice C: Serum glucose

  • The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.

Choice D: Heart rate

  • The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.

Choice G: Hematocrit

  • The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2

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