A nurse is reviewing the results of a biophysical profile for a client who is at 37 weeks of gestation. Which of the following findings indicates fetal well-being?
Amniotic fluid index of 1 cm
The fetus had four limb movements in 30 min.
Nonreactive nonstress test
The fetus had 20 seconds of sustained breathing movements in 30 min
The Correct Answer is B
A. An amniotic fluid index of 1 cm is abnormally low (oligohydramnios) and indicates potential fetal compromise, so this finding does not reflect fetal well-being.
B. Fetal limb movements are an important indicator of fetal activity and neurological function. Observing four or more discrete limb movements in 30 minutes meets one of the criteria for a reassuring biophysical profile, suggesting the fetus is active and neurologically intact.
C. A nonreactive nonstress test indicates the fetus is not showing adequate heart rate accelerations in response to movement, which can signal potential hypoxia or fetal compromise.
D. Sustained fetal breathing movements of 20 seconds in 30 minutes are desirable, but the minimum standard for the BPP is usually one or more episodes of 30 seconds within 30 minutes; 20 seconds alone may not meet the threshold, making limb movements a more reliable indicator in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An amniotic fluid index of 1 cm is abnormally low (oligohydramnios) and indicates potential fetal compromise, so this finding does not reflect fetal well-being.
B. Fetal limb movements are an important indicator of fetal activity and neurological function. Observing four or more discrete limb movements in 30 minutes meets one of the criteria for a reassuring biophysical profile, suggesting the fetus is active and neurologically intact.
C. A nonreactive nonstress test indicates the fetus is not showing adequate heart rate accelerations in response to movement, which can signal potential hypoxia or fetal compromise.
D. Sustained fetal breathing movements of 20 seconds in 30 minutes are desirable, but the minimum standard for the BPP is usually one or more episodes of 30 seconds within 30 minutes; 20 seconds alone may not meet the threshold, making limb movements a more reliable indicator in this scenario.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}
Explanation
- Administer an iron supplement: The client has low hemoglobin, hematocrit, RBCs, and ferritin, which are consistent with iron deficiency anemia. Iron supplementation is expected to help correct the deficiency and improve oxygen-carrying capacity.
- Refer for a nutritional consult: A vegan diet, if not properly planned, can lack adequate sources of iron and vitamin B12. A nutritionist can help the client meet dietary needs through fortified foods or supplements, addressing underlying causes of anemia.
- Place the client on a low sodium diet: The client’s blood pressure is within acceptable range, and there is no history of hypertension or fluid overload. A low sodium diet would not target the client’s current symptoms of anemia and fatigue.
- Restrict fluid intake: The client shows signs of volume depletion (orthostatic hypotension and low Hct) rather than fluid overload. Restricting fluids could worsen hypotension and contribute to decreased perfusion, making it inappropriate.
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