A nurse is performing a nonstress test (NST) for a pregnant client at 36 weeks of gestation who reports decreased fetal movement.
The nurse observes that the fetal heart rate (FHR) baseline is 120 bpm with minimal variability and no accelerations in a 20-minute period.
What should the nurse do next?
Offer the client a snack or juice to stimulate fetal activity
Apply an acoustic stimulator to elicit fetal movement
Stop the test and notify the provider immediately
Extend the test for another 20 minutes
The Correct Answer is A
Offer the client a snack or juice to stimulate fetal activity.
A nonstress test (NST) is a pregnancy screening that measures fetal heart rate and reaction to movement. It is performed to make sure the fetus is healthy and getting enough oxygen. A reactive NST means that the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice in a 20-minute period. A nonreactive NST means that this criteria is not met.
Choice B is wrong because applying an acoustic stimulator to elicit fetal movement is not recommended as a routine practice and may cause fetal distress.
Choice C is wrong because stopping the test and notifying the provider immediately is not necessary unless there are signs of fetal compromise, such as severe variable or late decelerations, or a nonreassuring fetal heart rate pattern.
Choice D is wrong because extending the test for another 20 minutes may not change the result and may prolong the discomfort of the client. A nonreactive NST does not mean there is a problem, but it may require further testing, such as a biophysical profile or a contraction stress test.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The test will require me to lie on my back for the duration of the test.This statement indicates a need for further teaching because lying on the back can compress the inferior vena cava and reduce blood flow to the baby.The test can be done in a reclining chair or on an exam table with a wedge under one hip to avoid this problem.
Choice A is correct because the test will measure how the baby’s heart rate changes when he moves.In most healthy babies, the heart rate increases during movement.
Choice B is correct because the test will take at least 20 minutes, but it may take longer if the baby is not active or moving during that time period.
Choice C is correct because the test will involve placing two belts around the abdomen.One will measure the baby’s heartbeat and the other will record contractions.
Correct Answer is A
Explanation
Reactive NST.This means that the fetal heart rate increased by at least 15 beats per minute (bpm) for at least 15 seconds twice or more in a 20-minute period.This indicates that the baby is getting enough oxygen and is doing well.
Nonreactive NST is wrong because it means that the fetal heart rate did not meet the criteria for a reactive NST.This could mean that the baby is not getting enough oxygen, is asleep, or has a problem with the nervous system.
Positive NST is wrong because it is not a term used to describe the results of a nonstress test.It is a term used to describe the results of a contraction stress test (CST), which is a different test that measures how the fetal heart rate responds to uterine contractions.
Negative NST is wrong because it is also not a term used to describe the results of a nonstress test.It is another term used to describe the results of a contraction stress test (CST), which means that the fetal heart rate did not show any signs of distress during contractions.
The normal range for fetal heart rate is 110 to 160 bpm, with moderate variability.
Variability refers to how much the heart rate changes from beat to beat.Moderate variability means that the heart rate changes by 6 to 25 bpm.Accelerations are brief increases in the heart rate that are usually caused by fetal movement.
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