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 A
Explanation
Choice A rationale:
Trisomy 21, also known as Down syndrome, is a genetic condition caused by the presence of an extra copy of chromosome 21.
The nuchal translucency test (NT) is a non-invasive ultrasound screening test that measures the thickness of the fluid-filled space at the back of a developing baby's neck.
Evidence suggests that fetuses with Down syndrome tend to have increased fluid accumulation in this area, resulting in a larger-than-average nuchal translucency measurement.
Therefore, an increased NT measurement can be a marker for an increased risk of Down syndrome.
It's important to emphasize that the NT test is a screening tool, not a diagnostic test.
This means it can only indicate an increased risk of Down syndrome; it cannot definitively diagnose the condition.
To confirm a diagnosis, further testing, such as chorionic villus sampling (CVS) or amniocentesis, is required.
Choice B rationale:
Neural tube defects (NTDs) are birth defects that affect the brain, spine, or spinal cord.
The most common NTDs are spina bifida and anencephaly.
The NT test is not a diagnostic test for NTDs, although it might detect some cases of open spina bifida.
However, it's not specifically designed for this purpose, and other tests, such as alpha-fetoprotein (AFP) screening or detailed ultrasound, are more reliable for diagnosing NTDs.
Choice C rationale:
The NT test is typically performed in the first trimester of pregnancy, between 11 and 14 weeks gestation.
It's not available in the second trimester because the nuchal translucency measurement becomes less reliable after this point in pregnancy.
Choice D rationale:
A nuchal translucency measurement of 3mm or less is generally considered normal.
Measurements greater than 3mm are associated with an increased risk of Down syndrome and other chromosomal abnormalities.
The higher the measurement, the greater the risk.
Correct Answer is B
Explanation
Choice A rationale:
While non-pharmacologic methods can promote relaxation and coping, they may not guarantee full alertness at all times.
The intensity of labor pain can vary significantly, and even non-pharmacologic methods may not completely prevent fatigue or exhaustion.
Factors such as prolonged labor, anxiety, or discomfort can still impact alertness.
Choice C rationale:
Non-pharmacologic methods often provide significant pain relief, but they may not achieve the same degree of pain control as pharmacologic options like epidural analgesia.
The level of pain relief experienced with non-pharmacologic methods can depend on individual factors, preferences, and the specific techniques used.
Choice D rationale:
While relaxation and reduced anxiety can sometimes contribute to a more efficient labor, there's no guarantee that nonpharmacologic methods will consistently lead to a more rapid labor.
The duration of labor is influenced by various factors, including the strength and frequency of contractions, the position of the fetus, and the mother's overall health and preparedness.
Choice B rationale:
Non-pharmacologic pain management techniques do not involve medications or interventions that could potentially have adverse effects on the fetus.
This makes them a safe and desirable option for many pregnant women who are concerned about the potential risks of pharmacologic pain relief.
Common non-pharmacologic techniques include:
Relaxation techniques (deep breathing, guided imagery, meditation)
Hydrotherapy (immersion in water, showers, hot or cold compresses)
Positioning and movement (walking, rocking, changing positions frequently)
Massage and touch therapy
Acupuncture and acupressure
Transcutaneous electrical nerve stimulation (TENS)
Biofeedback
Hypnosis
Continuous labor support (from a doula, partner, or other support person)
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