A nurse is teaching a client who is scheduled for a non-stress test. Which of the following information should the nurse include? Choice Options:
An IV will be initiated prior to the test.
The client will be asked to stimulate her nipples for 5 minutes during the test.
The client will receive an ultrasound prior to the test.
An external fetal monitor will be used to monitor the fetus.
The Correct Answer is D
Rationale for Choice A:
An IV is not routinely initiated prior to a non-stress test. It may be started if a biophysical profile (BPP), which includes an ultrasound, is also being performed, or if there is a risk of complications that may necessitate immediate intervention. However, it is not a standard part of the non-stress test itself.
Rationale for Choice B:
Nipple stimulation is not a standard component of a non-stress test. It may be used in some cases to try to induce fetal movement if the fetus is not moving actively enough during the test. However, it is not a routine part of the procedure.
Rationale for Choice C:
An ultrasound is not typically performed prior to a non-stress test. It may be done as part of a BPP, but it is not necessary for the non-stress test itself.
Rationale for Choice D:
An external fetal monitor is essential for conducting a non-stress test. This monitor uses two belts that are placed around the mother's abdomen. One belt measures the fetal heart rate, and the other belt measures uterine contractions. The monitor records the fetal heart rate and any contractions for a period of 20 to 40 minutes. The test is considered reactive (normal) if the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice during the test. This acceleration in heart rate is typically in response to fetal movement.
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Correct Answer is E
Explanation
Choice A rationale:
Placenta previa is a condition in which the placenta covers all or part of the cervix. It's a serious complication that can cause heavy bleeding during pregnancy and childbirth. However, it's not a direct complication of maternal gestational diabetes.
Choice B rationale:
Newborn hypoglycemia is a condition in which a newborn's blood sugar levels are too low. It can occur in infants of mothers with gestational diabetes, but it's not the most common or significant complication associated with the condition.
Choice C rationale:
Oligohydramnios is a condition characterized by a low amount of amniotic fluid around the baby. It can be associated with maternal gestational diabetes, but it's not as common as other complications, such as macrosomia (large for gestational age baby).
Choice D rationale:
Small for gestational age (SGA) newborn refers to a baby who is smaller than expected for their gestational age. It can be caused by several factors, including restricted intrauterine growth, which can be associated with maternal gestational diabetes. However, it's not the most direct or common complication of the condition.
Choice E rationale:
Maternal gestational diabetes is a condition in which a woman develops high blood sugar levels during pregnancy. It's the most common metabolic complication of pregnancy and can lead to several serious health risks for both the mother and baby. These risks include:
Macrosomia (large for gestational age baby): High blood sugar levels in the mother can cause the baby to grow excessively large, leading to complications during labor and delivery, such as shoulder dystocia, birth injuries, and cesarean delivery. Preeclampsia: Gestational diabetes increases the risk of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. It can affect multiple organs, including the liver and kidneys, and can be life-threatening for both mother and baby.
Premature birth: Women with gestational diabetes are more likely to deliver their babies prematurely, which can lead to health problems for the baby, such as respiratory distress syndrome, feeding difficulties, and developmental delays.
Neonatal hypoglycemia: Newborns of mothers with gestational diabetes are at increased risk of hypoglycemia (low blood sugar) after birth due to the sudden withdrawal of maternal glucose supply. This can cause seizures, brain damage, and even death if not promptly treated.
Type 2 diabetes later in life: Both mother and child are at increased risk of developing type 2 diabetes later in life.
Correct Answer is A
Explanation
Choice A:
Fetal heart tone location: In a frank breech presentation, the fetal buttocks are positioned downward and the legs are extended straight up toward the head, placing the fetal heart closer to the mother's upper abdomen. This results in fetal heart tones being heard above the umbilicus at midline.
Gestation period: At 9 weeks of gestation, the fetus is still small and has ample room to move within the uterus, making breech presentations more common. However, it's important to note that the ideal position for childbirth is cephalic, with the head down.
Other presentations:
Cephalic presentations typically have fetal heart tones below the umbilicus.
Transverse presentations usually have fetal heart tones laterally, off to one side of the abdomen.
Posterior presentations, while still head down, can have fetal heart tones that are difficult to locate or muffled due to the position of the fetal back against the mother's spine.
Choice B:
Fetal position: In a transverse presentation, the fetus is positioned horizontally across the uterus, with the head and buttocks on either side. This typically results in fetal heart tones being heard laterally, rather than above the umbilicus at midline.
Choice C:
Fetal position: In a cephalic presentation, the fetus is head down, with the buttocks near the fundus of the uterus. This usually results in fetal heart tones being heard below the umbilicus, rather than above it.
Choice D:
Fetal position: In a posterior presentation, the fetus is head down, but facing the mother's back. While this can sometimes make fetal heart tones difficult to locate, they are typically still heard below the umbilicus, rather than above it.
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