A nurse is caring for a client who is 35 weeks of gestation in the labor and delivery unit.

Exhibits

Based on the assessment findings, the physician plans to complete a BPP (biophysical profile). Which of the following is included in the BPP? (Select all that apply.)

Amniotic Fluid Index (AFI)

Fetal Breathing

Fetal Weight

Fetal Tone

Non-Stress Test (NST)

Fetal Movement

Answer and Explanation

Correct Answer : A,B,D,E,F

Choice A rationale: Amniotic Fluid Index (AFI) assesses the amniotic fluid volume, an important indicator of fetal well-being. Normal AFI ranges from 5 to 24 cm. Abnormal levels may indicate potential complications such as oligohydramnios or polyhydramnios.

Choice B rationale: Fetal breathing movements are a key component of the biophysical profile, reflecting fetal central nervous system integrity. Typically observed for at least 30 seconds in a 30-minute period, absence may suggest hypoxia or CNS issues.

Choice C rationale: Fetal weight is not included in the BPP as it does not directly measure acute fetal well-being. It is assessed through ultrasound for growth monitoring and determining if the fetus is appropriate for gestational age.

Choice D rationale: Fetal tone evaluates fetal central nervous system function by observing limb or trunk movements. Normal tone includes flexion and extension movements, while decreased tone may indicate hypoxia or CNS dysfunction.

Choice E rationale: Non-Stress Test (NST) measures fetal heart rate accelerations in response to fetal movements. A reactive NST indicates fetal well-being, with at least two accelerations within 20 minutes, while a non-reactive NST may require further evaluation.

Choice F rationale: Fetal movement assessment involves counting gross body movements over a specified period. At least three movements in 30 minutes are considered normal, reflecting fetal CNS integrity. Decreased movement may indicate compromised fetal health.

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Correct Answer is B

Explanation

Choice A rationale

Cord compression typically causes variable decelerations on the monitor, which are abrupt decreases in fetal heart rate, often with a U, V, or W shape.

Choice B rationale

Head compression leads to early decelerations, which are gradual decreases in fetal heart rate occurring with contractions. This pattern indicates head compression during labor.

Choice C rationale

Placental insufficiency results in late decelerations, where the fetal heart rate decreases after the peak of a contraction. This pattern suggests compromised placental blood flow.

Choice D rationale

Reactive NST (Non-Stress Test) indicates fetal well-being and is characterized by fetal heart rate accelerations, not decelerations.

A. Cervical dilation and effacement. B. Swelling of the feet and ankles. C. Nesting instinct. D. Increase in maternal blood pressure. E. Bloody show. F. Increase in Braxton Hicks contractions.

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

Explanation

Choice A rationale

Cervical dilation and effacement indicate the body is preparing for labor by allowing the cervix to open and thin out for childbirth.

Choice B rationale

Swelling of the feet and ankles is common in pregnancy due to increased fluid retention but is not a specific sign of imminent labor.

Choice C rationale

The nesting instinct, a burst of energy and urge to prepare the home, often occurs as labor approaches, driven by hormonal changes.

Choice D rationale

Increase in maternal blood pressure may indicate preeclampsia, a pregnancy complication, but not a premonitory sign of labor.

Choice E rationale

Bloody show involves the discharge of mucus with blood from the cervix, signaling that labor is likely to begin soon.

Choice F rationale

Increase in Braxton Hicks contractions, or practice contractions, helps the uterus prepare for true labor by strengthening muscles.

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A nurse is caring for a client who is 35 weeks of gestation in the labor and delivery unit. Exhibits Based on the assessment findings, the physician plans to complete a BPP (biophysical profile). Which of the following is included in the BPP? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in labor at term. The nurse reviews the external monitor tracing below. The nurse identifies that the deceleration pattern seen indicates which of the following?

Correct Answer is B

Explanation

Which of the following are premonitory signs of labor?

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

Explanation

A nurse is assisting a pregnant patient in labor who is experiencing discomfort. The nurse decides to use effleurage as a comfort measure. Which of the following best describes the technique of effleurage?

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A nurse is caring for a client who is 42 weeks of gestation in the labor and delivery unit. Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions?

A nurse is educating a patient on the interpretation of a positive contraction stress test. Which of the following explanations is correct?

A nurse is caring for a client who is 35 weeks of gestation in the labor and delivery unit. Exhibits Based on the assessment findings, the physician plans to complete a BPP (biophysical profile). Which of the following is included in the BPP? (Select all that apply.)

A nurse is caring for a client who is 35 weeks of gestation in the labor and delivery unit.

Exhibits

Based on the assessment findings, the physician plans to complete a BPP (biophysical profile). Which of the following is included in the BPP? (Select all that apply.)