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?
Discontinue oxytocin infusion and monitor the client for another 10 minutes
Increase oxytocin infusion and monitor the client until four contractions occur in 10 minutes
Stop oxytocin infusion and notify the provider of a positive CST result
Maintain oxytocin infusion and monitor the client until a negative CST result is confirmed
The Correct Answer is D
Maintain oxytocin infusion and monitor the client until a negative CST result is confirmed.
A negative CST result means that there are no late decelerations of the FHR after three contractions in 10 minutes. This indicates that the fetus can tolerate the stress of labor and has adequate oxygenation.
Choice A is wrong because discontinuing oxytocin infusion and monitoring the client for another 10 minutes will not provide enough information about the fetal response to contractions. The test requires at least three contractions in 10 minutes to be valid.
Choice B is wrong because increasing oxytocin infusion and monitoring the client until four contractions occur in 10 minutes may cause uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress.
Choice C is wrong because stopping oxytocin infusion and notifying the provider of a positive CST result is not appropriate. A positive CST result means that there are late decelerations of the FHR after more than half of the contractions, indicating fetal hypoxia and placental insufficiency.
In this case, there are no late decelerations, so the test result is not positive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Notify the provider and prepare for delivery.Oligohydramnios is a condition where the amniotic fluid volume is less than expected for gestational age and it is associated with maternal and fetal complications.
The nonstress test (NST) is a method of fetal surveillance that measures the fetal heart rate response to fetal movement.A reactive NST is defined as at least two accelerations of 15 beats per minute or more above the baseline, lasting 15 seconds or more, within a 20-minute period.
A nonreactive NST indicates fetal hypoxia or acidosis and requires further evaluation.An acoustic stimulator can be used to elicit fetal movement and accelerations, but it should not be repeated more than once in a 10-minute period.
Therefore, choice A is wrong because repeating the acoustic stimulation after 1 minute is too soon and may cause fetal distress.
Choice B is wrong because documenting the finding as a nonreactive NST is not enough to address the situation.Choice C is wrong because performing a contraction stress test (CST) is contraindicated in oligohydramnios because it may cause umbilical cord compression and fetal compromise.
The CST involves inducing uterine contractions with oxytocin or nipple stimulation and monitoring the fetal heart rate for signs of intolerance.
A negative CST means that there
Correct Answer is C
Explanation
Category III.This category of FHR tracing represents an abnormal pattern that is predictive of fetal acidemia and requires prompt evaluation and intervention.A category III pattern is defined by any of the following criteria:
• Absent baseline FHR variability and any of the following:
➤ Recurrent late decelerations
➤ Recurrent variable decelerations
➤ Bradycardia
• Sinusoidal pattern
Choice A is wrong because category I is a normal pattern that is predictive of normal fetal acid-base balance at the time of observation.A category I pattern is defined by all of the following criteria:
• Baseline rate of 110 to 160 bpm
• Moderate baseline FHR variability
• No late or variable decelerations
• Early decelerations may be present or absent
• Accelerations may be present or absent
Choice B is wrong because category II is an indeterminate pattern that is not predictive of abnormal fetal acid-base balance but requires continued surveillance and reevaluation.A category II pattern includes all FHR tracings that are not category I or III.
Choice D is wrong because there is no category IV in the NICHD classification system for FHR tracings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today