A nurse is reviewing the results of a fetal non-stress test (NST) for a client who is at 32 weeks of gestation.
The nurse notes that there are no accelerations of the fetal heart rate (FHR) during the 20-minute test.
Which of the following actions should the nurse take next? (Select all that apply.).
Repeat the NST after 24 hours
Perform a contraction stress test (CST).
Perform a biophysical profile (BPP)
Apply an acoustic vibration device to the abdomen
Administer oxygen via face mask to the client.
Correct Answer : C
Perform a biophysical profile (BPP). A BPP is a test that combines a non-stress test (NST) with an ultrasound to evaluate the fetal well-being. A BPP is indicated when an NST is non-reactive, meaning that there are no accelerations of the fetal heart rate (FHR) with fetal movements. A BPP measures five parameters: fetal movement, fetal tone, fetal breathing, amniotic fluid volume and FHR reactivity.
A BPP can help detect fetal hypoxemia or distress and guide further management.
Choice A is wrong because repeating the NST after 24 hours may delay the diagnosis and treatment of fetal compromise. A non-reactive NST requires further evaluation with a BPP or a contraction stress test (CST).
Choice B is wrong because performing a CST may not be safe for a fetus with a non-reactive NST.
A CST involves inducing uterine contractions with oxytocin or nipple stimulation and monitoring the FHR response. A CST can cause fetal distress or placental abruption if the fetus is already hypoxic.
Choice D is wrong because applying an acoustic vibration device to the abdomen may not elicit FHR accelerations if the fetus is hypoxic or asleep. An acoustic stimulation test (AST) is sometimes used to augment an NST, but it is not a substitute for a BPP.
Choice E is wrong because administering oxygen via face mask to the client may not improve the FHR reactivity if the cause of fetal compromise is not maternal hypoxia. Oxygen administration may also have adverse effects on maternal and fetal hemodynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The NST is reactive and normal for gestational age.This means that the fetal heart rate (FHR) accelerates at least 10 bpm for at least 10 seconds with each fetal movement, indicating that the fetus is healthy and getting enough oxygen.A reactive NST is expected for fetuses at 26 to 30 weeks of gestation.
Choice B is wrong because a nonreactive NST means that the FHR does not accelerate with fetal movement, which could indicate fetal distress or hypoxia.A nonreactive NST is abnormal for any gestational age and requires further evaluation.
Choice C is wrong because a reactive NST is not abnormal for gestational age.It is a normal finding that shows the fetus is well-oxygenated and responsive.
Choice D is wrong because a nonreactive NST is not normal for gestational age.It is an abnormal finding that suggests the fetus may be compromised or in need of intervention.
Correct Answer is D
Explanation
“You will need to press a button when you feel the baby move.” This is because a non-stress test (NST) is a pregnancy screening that measures fetal heart rate and reaction to movement.The test is performed to make sure the fetus is healthy and getting enough oxygen.By pressing a button when the baby moves, the patient can help the provider record the changes in the fetal heart rate.
Choice A is wrong because the patient does not need to fast for 8 hours before the test.There is no dietary restriction for an NST.
Choice B is wrong because the patient does not need to drink plenty of fluids before the test.However, drinking some fluids may help stimulate fetal movement.
Choice C is wrong because the patient does not need to lie on their back during the test.In fact, lying on the back can compress the blood vessels and reduce blood flow to the fetus.The patient can lie on their side or recline on a chair or exam table.
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