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 C
Explanation
Choice A rationale:
If both the mother and the father are Rh positive, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.
Choice B rationale:
When the mother is Rh positive and the father is Rh negative, there is no risk of hemolytic disease in the newborn. Hemolytic disease results from Rh incompatibility, which occurs when the mother is Rh negative, and the father is Rh positive.
Choice C rationale:
This is the correct answer. Hemolytic disease of the newborn occurs when the mother is Rh negative, and the father is Rh positive. In such cases, the baby may inherit the Rh factor from the father, leading to Rh incompatibility between the mother and the baby's blood, potentially causing hemolytic disease.
Choice D rationale:
If both the mother and the father are Rh negative, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.
Correct Answer is D
Explanation
Choice A rationale:
Telangiectatic nevi are commonly known as "stork bites”. or "angel kisses”. and are superficial vascular areas commonly found on the nape of the neck or the eyelids of newborns? These are benign and pose no significant health risks.
Choice B rationale:
Erythema toxicum is a common, benign skin rash that appears in the first few days of life. It presents as small, raised red spots with a surrounding halo and is not related to a nuchal cord.
Choice C rationale:
Periauricular papillomas, also known as "ear tags,”. are small, skin-coloured nodules that can be found near the external ear. They are also benign and unrelated to a nuchal cord.
Choice D rationale:
Facial petechiae are tiny, red or purple pinpoint spots on the skin caused by minor haemorrhages. In newborns, facial petechiae can be associated with a nuchal cord, which is a condition where the umbilical cord is wrapped around the baby's neck during delivery. This condition is relatively common and usually resolves without complications. The nurse should monitor the baby for any signs of distress or complications related to the nuchal cord.
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