A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?
Kleihauer-Betke test
Amnioinfusion
Administration of terbutaline
Contraction stress test
The Correct Answer is D
A. Kleihauer-Betke test. This test is used to detect fetal-maternal hemorrhage by identifying fetal red blood cells in maternal circulation. It is not related to a nonreactive NST, which indicates the need for further fetal well-being assessment rather than checking for fetal-maternal bleeding.
B. Amnioinfusion. This procedure involves infusing fluid into the amniotic sac to relieve umbilical cord compression or dilute meconium-stained amniotic fluid. It is not an appropriate intervention for a nonreactive NST, as it does not assess fetal oxygenation or reactivity.
C. Administration of terbutaline. Terbutaline is a tocolytic used to relax the uterus and prevent preterm labor. It is not indicated for a nonreactive NST, as the concern in this scenario is fetal well-being rather than uterine activity.
D. Contraction stress test. A nonreactive NST means that the fetal heart rate does not demonstrate adequate accelerations, which can indicate potential fetal hypoxia. A contraction stress test is performed next to evaluate how the fetal heart rate responds to contractions, helping determine if the fetus can tolerate labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Apply intermittent suction for 30 seconds. Suctioning should not exceed 10-15 seconds to minimize hypoxia and irritation to the airway. Continuous suctioning for 30 seconds can lead to discomfort and inadequate oxygenation.
B. Apply suction while inserting the catheter. Suction should not be applied while inserting the catheter. This technique can cause trauma to the mucosa and prevent effective suctioning. Suction should only be applied once the catheter is in the desired position.
C. Insert the catheter 10 cm (4 in). The appropriate insertion depth for nasopharyngeal suctioning is typically 12-15 cm (5-6 in) for adults. Inserting the catheter to the proper depth ensures effective suctioning of secretions while minimizing the risk of injury.
D. Wait 1 min between suctioning attempts. Waiting 1 minute between suctioning attempts is essential to allow for adequate oxygenation and to prevent trauma to the airway. This interval allows the client to recover and ensures the airway is not overly irritated or compromised.
Correct Answer is B
Explanation
A. Administer granulocyte colony-stimulating factor. This medication stimulates neutrophil production in clients with severe neutropenia, such as those undergoing chemotherapy. While HIV can cause neutropenia, routine administration is not necessary unless the infant has recurrent infections and significantly low neutrophil counts.
B. Monitor the infant's lymphocyte count. CD4+ T-cell levels are key indicators of immune function in infants with HIV. Since HIV targets these cells, regular monitoring helps assess disease progression and the effectiveness of antiretroviral therapy, guiding treatment adjustments when needed.
C. Educate the infant's guardians about exchange transfusions. Exchange transfusions are used for conditions like severe neonatal hyperbilirubinemia or sickle cell disease, not HIV. Managing HIV in infants focuses on early antiretroviral therapy, routine lab monitoring, and infection prevention.
D. Initiate droplet precautions. Standard precautions, such as hand hygiene and appropriate use of personal protective equipment, are sufficient for infection control. HIV is not transmitted through respiratory droplets but through direct contact with infected blood, breast milk, or other bodily fluids.
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