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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

Uterine contractions: hallmark of preterm labor but not typical of PPROM alone unless labor ensues.
Low backache: common symptom of preterm labor due to uterine activity and pelvic changes; not directly associated with PPROM unless labor begins.
Vaginal discharge: can be increased in both preterm labor (e.g., mucus plug changes, bloody show) and PPROM (amniotic fluid leakage or altered discharge).
Cervical effacement: characteristic of labor process (preterm labor), not typically present in PPROM unless labor starts.

A. Institute droplet precautions. B. Administer ceftriaxone sodium. C. Inform the client they should bottlefeed the newborn. D. Obtain surface cultures from the newborn.

Correct Answer is D

Explanation

Choice A rationale

Droplet precautions are implemented for pathogens transmitted via large respiratory droplets, such as influenza or meningococcal disease. Herpes simplex virus is typically transmitted through direct contact with lesions or secretions, not primarily through airborne droplets. Therefore, instituting droplet precautions would not be the most scientifically appropriate measure for preventing HSV transmission in this context.

Choice B rationale

Ceftriaxone sodium is a broad-spectrum cephalosporin antibiotic used to treat bacterial infections, such as gonorrhea or bacterial meningitis. Herpes simplex virus is a viral infection, and antibiotics are ineffective against viruses. Administering ceftriaxone would not address the underlying viral etiology of the newborn's exposure to HSV.

Choice C rationale

Bottle-feeding the newborn is not a primary intervention to prevent transmission of HSV from a mother with active genital herpes to a newborn. HSV is transmitted through direct contact during passage through the birth canal. Breastfeeding is generally considered safe for mothers with HSV unless there are active lesions on the breast.

Choice D rationale

Obtaining surface cultures from the newborn is a crucial diagnostic step to confirm the presence of HSV infection in a neonate exposed during birth. This allows for timely initiation of antiviral therapy, such as acyclovir, which is essential to prevent systemic dissemination and severe complications like encephalitis, which can be life-threatening in newborns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

A nurse is planning care for a newborn who was exposed to active genital herpes simplex virus (HSV) during birth. Which of the following nursing actions should the nurse anticipate?

Correct Answer is D

Explanation

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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?