A nurse is evaluating the results of a contraction stress test (CST) for a pregnant client who had a nonreactive or nonreassuring result on a nonstress test (NST).
The nurse notes that there are no late decelerations of the fetal heart rate (FHR) after three contractions in a 10-minute period.
How should the nurse interpret this finding?
Positive or abnormal
Negative or normal
Equivocal or suspicious
Unsatisfactory or incomplete
The Correct Answer is B
Negative or normal. This means that there are no late decelerations of the fetal heart rate (FHR) after three contractions in a 10-minute period, which indicates that the baby can tolerate the stress of labor contractions.
Choice A is wrong because positive or abnormal results mean that there are late decelerations of the FHR after three contractions in a 10-minute period, which suggests that the baby may be at risk of hypoxia or injury during labor.
Choice C is wrong because equivocal or suspicious results mean that there are either variable decelerations or late decelerations after fewer than half of the contractions, which require further testing or monitoring.
Choice D is wrong because unsatisfactory or incomplete results mean that there are either fewer than three contractions in a 10-minute period or poor quality of the FHR tracing, which prevent an accurate interpretation of the test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
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.
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