A nurse is performing a non-stress test (NST) for a client who is 34 weeks pregnant and has pre-eclampsia.
Which of the following fetal heart rate patterns indicates a reactive test?
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period
No accelerations or decelerations in a 20-minute period
One acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period
Variable decelerations with normal variability in a 20-minute period
The Correct Answer is A
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period. This indicates a reactive test, which means that the fetus is well oxygenated and not in distress.
Choice B is wrong because no accelerations or decelerations in a 20-minute period indicate a non-reactive test, which may suggest fetal hypoxia or acidosis.
Choice C is wrong because one acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period is the criterion for a reactive test for gestational age less than 32 weeks, not 34 weeks.
Choice D is wrong because variable decelerations with normal variability in a 20-minute period indicate cord compression or fetal head compression, not a reactive test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor the client’s deep tendon reflexes hourly because magnesium sulfate can cause neuromuscular blockade and decreased reflexes.The nurse should keep calcium gluconate readily available because it is the antidote for magnesium toxicity.The nurse should maintain a urine output of at least 40 mL/hr because magnesium is excreted by the kidneys and low urine output can indicate renal impairment or fluid overload.The nurse should check the client’s blood pressure every 15 minutes because magnesium sulfate can cause hypotension and preeclampsia can cause hypertension.
Choice D is wrong because the medication should not be infused via a peripheral IV line, but rather through a central line or a large-bore IV catheter to prevent tissue damage.
Correct Answer is D
Explanation
Protein excretion of 450 mg indicates proteinuria.Proteinuria is the presence of excess protein in the urine, which can be a sign of kidney damage or disease.Normal protein excretion in a 24-hour urine collection is less than 150 mg.
Choice A is wrong because protein excretion of 150 mg is within the normal range.
Choice B is wrong because protein excretion of 250 mg is slightly above the normal range, but not enough to indicate proteinuria.
Choice C is wrong because protein excretion of 350 mg is also above the normal range, but not enough to indicate proteinuria.
Preeclampsia is a condition that affects some pregnant women, usually after 20 weeks of pregnancy.It causes high blood pressure and proteinuria, which can harm both the mother and the baby.A 24-hour urine collection is a simple lab test that measures what’s in the urine and checks kidney function.The test is done by collecting all the urine passed in a 24-hour period in a special container that must be kept cool until returned to the lab.
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