A nurse is observing fetal breathing movements on an ultrasound for a client who is undergoing a biophysical profile (BPP).
The nurse should document how many points for this variable if the fetus has at least one episode of breathing lasting for 20 seconds within a 30-minute period?
0 points.
1 point.
2 points.
3 points.
The Correct Answer is C
According to the ACOG guidelines on antepartum fetal surveillance, one of the components of the biophysical profile is fetal breathing movements, which are scored as 2 points if there is one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes.
Choice A is wrong because 0 points are given for absent or no breathing episode for ≥30 seconds within a 30 minute observation period.
Choice B is wrong because there is no 1 point score for this variable.
Choice D is wrong because there is no 3 point score for this variable.
The maximum score for each variable is 2 points.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“I will have sensors placed on my abdomen to monitor the FHR and uterine contractions.” This statement indicates the client understands the test procedure of a CST, which is a test that triggers contractions and registers how the baby’s heart reacts.
The test is done by placing two sensor belts around the abdomen, one to measure the baby’s heartbeat and the other to measure contractions.
The client may receive oxytocin through an IV to induce contractions.
Choice B is wrong because the client does not need to fast for 24 hours before the test.
There is no evidence that fasting is required for a CST.
Choice C is wrong because the client will not be sedated during the test.
Sedation is not necessary for a CST and may interfere with the results.
Choice D is wrong because the client does not need to drink plenty of fluids before the test.
There is no evidence that drinking fluids is required for a CST.
Correct Answer is B
Explanation
The correct answer is choice B. Monitor fetal heart rate.
This is because cramping and vaginal bleeding after amniocentesis are signs of possible complications such as miscarriage, preterm labor, or injury to the fetus.
Monitoring fetal heart rate can help assess the well-being of the fetus and detect any signs of distress.
Choice A is wrong because administering Rho(D) immunoglobulin is only necessary if the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause Rh sensitization.
This is not given routinely to all women who have amniocentesis.
Choice C is wrong because assessing maternal vital signs is not the first priority when there is a risk of fetal compromise.
Maternal vital signs can be affected by many factors and are not specific indicators of fetal health.
Choice D is wrong because obtaining an order for an ultrasound exam is not the first action to take.
An ultrasound exam can help confirm the diagnosis of complications such as placental abruption or fetal demise, but it requires time and equipment that might delay immediate intervention.
Monitoring fetal heart rate can be done quickly and easily at the bedside.
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