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 B
Explanation
Lecithin/sphingomyelin (L/S) ratio.
This is a test that measures the amount of two phospholipids in the amniotic fluid that are important for the production of surfactant, a substance that helps the lungs expand and prevents them from collapsing.A higher L/S ratio indicates more surfactant and greater fetal lung maturity.The normal range for L/S ratio is 2:1 or higher at term.
Choice A is wrong because alpha-fetoprotein (AFP) is a protein produced by the fetus that can be measured in the amniotic fluid or maternal blood.It is used to screen for neural tube defects and other abnormalities, not for fetal lung maturity.
Choice C is wrong because Kleihauer-Betke test is a blood test that detects fetal red blood cells in the maternal circulation.It is used to diagnose fetomaternal hemorrhage, a condition where fetal blood leaks into the mother’s blood, not for fetal lung maturity.
Choice D is wrong because indirect Coombs’ test is a blood test that detects antibodies in the mother’s blood that may attack the fetal red blood cells.It is used to screen for Rh incompatibility or other blood group sensitization, not for fetal lung maturity.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is choice A, B, C and D.These are the four components of a biophysical profile (BPP) that are scored as 2 (normal) or 0 (abnormal) based on ultrasound examination.The fifth component is the nonstress test (NST) that measures the fetal heart rate reactivity.A total score of 8 or 10 is normal, 6 is equivocal, and 4 or less is abnormal.
Choice E is wrong because fetal position is not a part of the BPP score.Fetal position is determined by ultrasound but it does not affect the score.
Normal ranges for each component are:
• Fetal breathing movement: One or more episodes of fetal breathing lasting at least 30 seconds within 30 minutes.
• Fetal tone: One or more episodes of active extension and flexion of a fetal extremity or opening and closing of the hand within 30 minutes.
• Reactive fetal heart rate: Two or more fetal heart rate accelerations that peak at least 15 beats per minute above the baseline and last at least 15 seconds from baseline to baseline during 20 minutes of observation.
• Amniotic fluid volume: A single deepest vertical pocket of amniotic fluid that measures at least 2 centimeters.
• Gross body movement: Three or more discrete body or limb movements within 30 minutes.
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