A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?
An FHR that peaks 20 beats above the baseline.
Three uterine contractions within a 20-min period.
One acceleration of the FHR within a 20-min period.
Uterine contractions lasting 20 to 30 seconds each.
The Correct Answer is C
The correct answer is choice c. One acceleration of the FHR within a 20-min period.
Here's the rationale for each choice:
Choice A: Rationale: A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.
Choice B: Rationale: While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.
Choice C: Rationale: A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.
Choice D: Rationale: Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is C
Explanation
Listeriosis is a foodborne illness that can have severe consequences during pregnancy. To minimize the risk of listeriosis, a pregnant client should avoid certain foods that are more likely to be contaminated with the bacteria Listeria. The correct statement that indicates an understanding of the teaching is:
C) "I can eat grilled chicken on a bun at lunchtime."
Grilled chicken is a safe option, and as long as it's properly cooked, it's a suitable choice during pregnancy. The other options are not recommended during pregnancy:
A) Soft cheeses, like Brie or feta, can carry a risk of Listeria contamination, so they should be avoided.
B) Seafood salad from the grocery store may not be safe as it could contain seafood that's been sitting at improper temperatures, which can increase the risk of foodborne illness.
D) Hot dogs can also be a risk as they are often not served steaming hot, which is necessary to kill any potential Listeria contamination.
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