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","C"]
Explanation
Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension.The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption.The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.
Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.
Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.
Statement E is wrong because assessing for signs of placental abruption is not enough.The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.
Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women.Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.
Correct Answer is A
Explanation
According to Mayo Clinic, loss of reflexes is a sign of magnesium toxicity and requires immediate intervention.
Other signs of magnesium toxicity include:
• Decreased urine output
• Difficulty breathing
• Drowsiness or confusion
• Low blood pressure
• Slow heart rate
• Weakness
Choice B is wrong because headache is not a sign of magnesium toxicity.
It may be a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Choice C is wrong because nausea is not a sign of magnesium toxicity.
It may be a side effect of magnesium sulfate or a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Choice D is wrong because blurred vision is not a sign of magnesium toxicity.
It may be a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
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