A pregnant client is undergoing a nipple-stimulated contraction stress test (CST). She is experiencing contractions every three minutes.
The fetal heart rate (FHR) baseline is approximately 120 beats/min with no decelerations.
How should the nurse document this test?
Satisfactory
Unsatisfactory.
Negative.
Positive.
The Correct Answer is C
The correct answer is choice c. Negative.
Choice A rationale:
“Satisfactory” is not a standard term used to describe the results of a contraction stress test (CST). The terms typically used are “negative,” “positive,” “equivocal,” or “unsatisfactory.”
Choice B rationale:
“Unsatisfactory” is used when the test cannot be interpreted due to inadequate contractions or other technical issues. In this case, the client is experiencing contractions every three minutes, and the fetal heart rate (FHR) is being monitored effectively.
Choice C rationale:
A “Negative” CST indicates that there are no late decelerations of the FHR during contractions, suggesting that the fetus is not experiencing significant distress and is likely tolerating the contractions well.
Choice D rationale:
A “Positive” CST would indicate the presence of late decelerations of the FHR with at least 50% of contractions, suggesting fetal hypoxia and compromised placental function. Since there are no decelerations in this scenario, this choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. The test results are normal.
Choice A rationale:
A biophysical profile (BPP) score of 8 does not necessarily indicate a need for immediate cesarean delivery.
Cesarean delivery is typically reserved for cases where there is a clear and urgent risk to the health of the mother or fetus, such as severe fetal distress or placental abruption.
A score of 8, while not the highest possible score, is still within the normal range and does not, by itself, constitute a reason for immediate surgical intervention.
Choice B rationale:
Additional tests may be considered in certain cases, such as when the BPP score is borderline or when there are other risk factors present.
However, a score of 8 is generally considered reassuring and does not typically warrant further testing.
It's essential to evaluate the BPP score in the context of the overall clinical picture, including the gestational age, maternal health, and fetal history.
Choice D rationale:
While an obstetric specialist may review the BPP results and discuss delivery options with the patient, this is not typically done within a week for a score of 8.
A score of 8 indicates reassuring fetal well-being, and there is usually no need for such urgent consultation or decision-making.
The timing of delivery discussions would depend on the overall clinical situation and the patient's individual preferences.
Choice C rationale:
A BPP score of 8 is considered normal.
It suggests that the fetus is well-oxygenated and has normal heart rate, breathing movements, muscle tone, and amniotic fluid levels.
This score does not raise immediate concerns about fetal well-being and does not typically require any immediate interventions.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Prostaglandins:
Mechanism of action: Prostaglandins are hormone-like substances that play a crucial role in labor initiation. They act by softening and ripening the cervix, stimulating uterine contractions, and rupturing the amniotic sac.
Types: Prostaglandins used for labor induction include:
Dinoprostone (Cervidil, Prepidil): Inserted into the vagina as a gel or pessary.
Misoprostol (Cytotec): Administered orally or vaginally.
Effectiveness: Generally effective in initiating labor within 24 hours, with success rates ranging from 60-85%.
Advantages:
Can be used when the cervix is unfavorable (not ripe).
Can be administered in a variety of ways to suit the patient's preferences.
May have a lower risk of uterine hyperstimulation compared to oxytocin.
Disadvantages:
Can cause side effects such as nausea, vomiting, diarrhea, and fever.
May increase the risk of uterine rupture, especially in women with a history of cesarean delivery.
Choice D rationale:
Amnioinfusion:
Procedure: Involves the infusion of sterile saline solution into the amniotic sac through a small catheter.
Mechanism of action: Not fully understood, but it's thought to work by:
Increasing amniotic fluid volume, which can help to stimulate contractions.
Stretching the uterine walls, which may trigger the release of prostaglandins.
Reducing pressure on the umbilical cord, which can improve fetal oxygenation.
Effectiveness: Usually used in conjunction with other induction methods, such as oxytocin or prostaglandins. Has a success rate of about 50-60% in initiating labor within 24 hours.
Advantages:
May be helpful in cases of low amniotic fluid (oligohydramnios).
Can decrease the risk of umbilical cord compression.
Disadvantages:
Requires the insertion of a catheter into the uterus, which carries a small risk of infection.
May cause discomfort for the mother.
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