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 minutes.
Administer an intravenous fluid bolus.
Prepare the client for cesarean birth.
Allow the labor to progress naturally.
The Correct Answer is D
Choice A rationale
A negative contraction stress test (CST) indicates that the fetus tolerates uterine contractions well, with no evidence of late decelerations, implying adequate uteroplacental function. Repeating the test in 20 minutes is unnecessary as a negative result signifies fetal well-being and is a favorable outcome.
Choice B rationale
Administering an intravenous fluid bolus is often used in situations like non-reassuring fetal heart rate patterns or to improve uteroplacental perfusion, such as during a non-reactive non-stress test or before an oxytocin challenge. A negative CST indicates a healthy fetus, so a fluid bolus is not indicated.
Choice C rationale
Preparing for a cesarean birth is indicated when there is evidence of fetal distress or a high risk of adverse outcomes, such as with a positive CST (late decelerations present). A negative CST indicates a reassuring fetal status, making a cesarean birth unnecessary based solely on these test results.
Choice D rationale
A negative CST indicates a healthy fetus with good uteroplacental reserve, suggesting that the fetus will likely tolerate the stress of labor. Therefore, allowing the labor to progress naturally is the appropriate action, as there are no indications of fetal compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In the scenario of ruptured membranes with a breech presentation, there is an elevated risk of umbilical cord prolapse due to the disproportionate fit of the presenting part in the maternal pelvis. Checking fetal heart tones immediately allows for rapid detection of cord compression, which manifests as abrupt decelerations, indicating fetal distress and necessitating urgent intervention.
Choice B rationale
While a cesarean birth is often indicated for breech presentations, especially with ruptured membranes, it is not the immediate first action. The priority is to assess fetal well-being, specifically ruling out umbilical cord prolapse, as this is an acute emergency that requires immediate intervention to prevent fetal hypoxia and mortality, prior to surgical preparation.
Choice C rationale
Assessing the color, amount, and odor of the amniotic fluid provides information about potential infection or meconium presence, which are important data points. However, the immediate life-threatening complication with ruptured membranes and breech presentation is umbilical cord prolapse, making fetal heart tone assessment a more urgent priority.
Choice D rationale
Performing a Nitrazine test confirms the rupture of membranes, but the client has already reported "my water just broke.”. While a confirmatory test, it is not the immediate priority. The critical concern is the potential for umbilical cord prolapse, which directly impacts fetal oxygenation and requires immediate assessment via fetal heart tones.
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit can inadvertently convey a message of displacement to the older sibling. This is due to the older child's developing cognitive understanding of parental attention and resources. The immediate focus on the new baby might lead to feelings of jealousy or being replaced, potentially hindering positive sibling bonding.
Choice B rationale
Spending individual time with the older sibling reinforces their continued importance within the family structure. This dedicated attention helps mitigate feelings of neglect or competition, promoting a sense of security and love. It allows the older child to process the family change and feel valued, fostering a more positive acceptance of the newborn.
Choice C rationale
While involving the older sibling in purchasing a gift can be a positive step, it might not fully address the emotional and psychological adjustments required. The act itself is a superficial gesture and doesn't substitute for direct parental reassurance and quality time, which are crucial for true sibling acceptance and emotional well-being.
Choice D rationale
Postponing the introduction can create anxiety and resentment in the older sibling. Children often perceive delays as exclusion or secrecy, which can foster negative feelings towards the new baby. An early, supervised introduction, with parental guidance, allows for a more natural and integrated family adjustment.
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