A nurse is performing a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "what are you looking for during this test?" Which of the following responses should the nurse make?
"We are looking for increases in fetal heart rate of 15 beats per minute for at least 15 seconds.
"We will draw blood to evaluate the baby's risk of genetic problems.”.
"If the baby moves 5 times in 15 minutes, then the baby is healthy.”.
"I am looking at the ultrasound to see if the baby has any congenital anomalies.”.
The Correct Answer is A
Choice A rationale
A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.
Choice B rationale
Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.
Choice C rationale
While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.
Choice D rationale
Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
- Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
- Uterine findings: Expected—firm and midline uterus indicating effective involution.
- Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
- Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
- Blood pressure: Expected—within normal postpartum range.
Correct Answer is C
Explanation
Choice A rationale
Immediately postpartum, the fundus is typically palpable. It gradually descends into the pelvic cavity over the following days.
Choice B rationale
By 6 to 12 hours postpartum, the fundus is usually located at the level of the umbilicus or slightly below it. It descends approximately one fingerbreadth (1 cm) per day.
Choice C rationale
In the immediate postpartum period, within the first few hours after delivery, the nurse should expect to find the fundus at the level of the umbilicus. This indicates that the uterus is contracting to control bleeding at the placental site.
Choice D rationale
Immediately after delivery, the fundus is typically higher than the symphysis pubis. It descends into the abdomen as the uterus contracts and the placental site begins to heal. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.