A nurse is caring for a client who is undergoing an external nonstress test at 40 weeks of gestation and notes variable decelerations on the fetal monitor tracing that are unresponsive to interventions such as repositioning and oxygen administration.

Which of the following actions should the nurse take next?

Prepare the client for an amnioinfusion

Apply an internal fetal scalp electrode

Administer IV fluid bolus to the client

Discontinue oxytocin infusion if present

Answer and Explanation

The Correct Answer is A

Prepare the client for an amnioinfusion. An amnioinfusion is a procedure that adds fluid to the uterus during labor to relieve cord compression and improve fetal condition. Variable decelerations on the fetal monitor tracing are a sign of cord compression and fetal distress. If repositioning and oxygen administration do not resolve the decelerations, an amnioinfusion may be indicated.

Choice B is wrong because applying an internal fetal scalp electrode does not address the cause of variable decelerations, which is cord compression.

An internal fetal scalp electrode is used to monitor the fetal heart rate more accurately, but it does not improve fetal oxygenation or prevent cord compression.

Choice C is wrong because administering IV fluid bolus to the client may help increase maternal blood volume and placental perfusion, but it does not directly increase amniotic fluid volume or relieve cord compression.

Choice D is wrong because discontinuing oxytocin infusion if present may reduce uterine contractions and decrease cord compression, but it may also prolong labor and increase the risk of infection or fetal compromise. Oxytocin infusion should only be discontinued if there are signs of uterine hyperstimulation or fetal intolerance.

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Correct Answer is D

Explanation

Notify the health care provider.Late decelerations are a sign of uteroplacental insufficiency, which means that the blood flow and oxygen supply to the placenta and the fetus are compromised.This is a serious condition that can lead to fetal hypoxia and acidosis.The priority nursing intervention is to inform the health care provider who can assess the situation and decide on the appropriate course of action, such as delivery by cesarean section.

Choice A is wrong because changing the client’s position may not improve the blood flow to the placenta if there is a problem with the placenta itself, such as placental abruption.

Choice B is wrong because administering oxygen via face mask may not be enough to correct the fetal hypoxia caused by uteroplacental insufficiency.

Choice C is wrong because increasing intravenous fluid rate may not improve the blood flow to the placenta if there is a problem with the maternal blood pressure, such as hypotension from epidural analgesia.

A. Place the device over the fetal back for 3 seconds B. Hold the device firmly against the maternal abdomen for 10 seconds C. Move the device around the maternal abdomen until fetal movement is detected D. Apply the device intermittently over the fundus for 15 seconds

Correct Answer is A

Explanation

Place the device over the fetal back for 3 seconds.This is because vibroacoustic stimulation (VAS) is the application of a vibratory sound stimulus to the abdomen of a pregnant woman to induce fetal heart rate (FHR) accelerations.The presence of FHR accelerations reliably predicts the absence of fetal metabolic acidemia.VAS is typically used during a nonstress test (NST) to assess fetal well-being.The device should be placed over the fetal back for 3 seconds, as this is the optimal duration and location to elicit a fetal response.

Choice B is wrong because holding the device firmly against the maternal abdomen for 10 seconds may be too long and too strong for the fetus, and may cause discomfort or distress.

Choice C is wrong because moving the device around the maternal abdomen until fetal movement is detected may not be effective or efficient, as the device may not reach the optimal location or duration to stimulate the fetus.

Choice D is wrong because applying the device intermittently over the fundus for 15 seconds may not target the fetal auditory system, which is located near the fetal back, and may also be too long and too strong for the fetus.

Normal ranges for FHR are between 110 and 160 beats per minute, and FHR accelerations are defined as an increase of at least 15 beats per minute above baseline for at least 15 seconds.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in labor who has an internal fetal scalp electrode applied for continuous fetal heart rate (FHR) monitoring. The nurse notes a pattern of late decelerations on the FHR tracing. What is the priority nursing intervention?

Correct Answer is D

Explanation

A nurse is using vibroacoustic stimulation (VAS) to stimulate fetal movement during a nonstress test (NST). What action should the nurse take when applying VAS?

Correct Answer is A

Explanation

A nurse is caring for a client who is undergoing an oxytocin-stimulated contraction stress test (CST). The nurse observes three contractions in 10 minutes with no late decelerations of the fetal heart rate (FHR). Which of the following actions should the nurse take?

A nurse is providing discharge instructions to a client who had a nonreactive nonstress test (NST) followed by a biophysical profile (BPP) with a score of 8/10. Which of the following statements by the client indicates an understanding of the teaching?

(Select all that apply) A nurse is performing a nonstress test (NST) for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. The nurse uses vibroacoustic stimulation to elicit fetal movement and acceleration of FHR. What are the indications for using this method?

A nurse is caring for a client who is pregnant and undergoing a contraction stress test (CST). The nurse observes three uterine contractions in 10 minutes, with no late or significant variable decelerations of the fetal heart rate (FHR). How should the nurse interpret this finding?

A nurse is assessing a fetal heart rate (FHR) tracing for a client who is in active labor. The nurse notes that the baseline FHR is 150 bpm with absent variability and recurrent variable decelerations with slow return to baseline. What category of FHR tracing does this represent?

A nurse is comparing nonstress test (NST) and contraction stress test (CST) for assessing fetal well-being. What is an advantage of NST over CST?

A nurse is reviewing the findings of a biophysical profile (BPP) for a client who is at 40 weeks of gestation. The BPP score is 6 out of 10 points. Which of the following components are included in this score? (Select all that apply.)