A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation.The results of the test indicate a negative CST.
Which of the following actions should the nurse take?
Repeat the CST in 20 min.
Administer an IV fluid bolus.
Prepare the client for cesarean birth.
Allow the labor to progress naturally.
The Correct Answer is D
Choice A rationale
Repeating the CST isn't necessary with a negative result, which indicates no significant uterine contractions affecting the fetus.
Choice B rationale
Administering an IV fluid bolus is not warranted by a negative CST result.
Choice C rationale
Preparing for a cesarean birth isn't necessary since a negative CST indicates no immediate fetal distress.
Choice D rationale
A negative CST indicates that there are no late decelerations, so the nurse should allow the labor to progress naturally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.
Choice B rationale
Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.
Choice C rationale
Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.
Choice D rationale
Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.
Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.
Choice C rationale
Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.
Choice D rationale
An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.