A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta.

Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?

Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

The correct answer is Choice C.

A nonstress test (NST) is a safe and noninvasive test used to check a baby’s health before birth. NSTs are a form of electronic fetal monitoring. In addition, nonstress tests are normally performed 26 to 30 weeks into pregnancy. This is because, in healthy babies, fetal heart rate increases with movement.

Nonstress test results are given as one of the following:

Reactive or Reassuring. This means the baby’s heart rate increased two or more times during the testing period.

Nonreactive. This means the baby’s heartbeat didn’t change when the baby moves, or the baby wasn’t moving much. A nonreactive result doesn’t always mean your baby has a health problem.

Based on this information, the correct answer to your question is c. Three fetal movements perceived by the client in a 20-min testing period indicate a nonreactive result, which should prompt further diagnostic testing. The other options are normal or reassuring findings for a nonstress test.

Choice A rationale: An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding and indicates a reactive nonstress test. A reactive nonstress test means that the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds in response to fetal movement, at least twice in a 20-min period. This shows that the fetus is well-oxygenated and has an intact central nervous system. Therefore, this finding does not indicate the need for further diagnostic testing.

Choice B rationale: No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is also a normal finding and indicates a negative contraction stress test. A negative contraction stress test means that there are no late decelerations in the fetal heart rate with at least three uterine contractions of 40 to 60 seconds in duration within a 10-min period. Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia, and they occur when the fetal heart rate drops below the baseline after the peak of the contraction. Therefore, this finding does not indicate the need for further diagnostic testing.

Choice C rationale: Three fetal movements perceived by the client in a 20-min testing period is an abnormal finding and indicates a nonreactive nonstress test. A nonreactive nonstress test means that the fetal heart rate does not increase by at least 15 beats per minute for at least 15 seconds in response to fetal movement, even after 40 min of testing. This may suggest that the fetus is asleep, sedated, or compromised. Therefore, this finding indicates the need for further diagnostic testing, such as a biophysical profile or a contraction stress test, to assess the fetal well-being.

Choice D rationale: Irregular contractions of 10 to 20 seconds in duration that are not felt by the client are not relevant to the nonstress test, as they do not affect the fetal heart rate or the uteroplacental perfusion. These contractions may be Braxton Hicks contractions, which are painless and irregular contractions that occur throughout pregnancy. They do not indicate labor or fetal distress. Therefore, this finding does not indicate the need for further diagnostic testing.