A pregnant client, who is 35 weeks along, comes in for weekly fetal heart monitoring.
After 20 minutes on the monitor, the fetal heart rate tracing shows three accelerations measuring 15 beats by 15 seconds.
How should the nurse report this finding to the provider?
Positive contraction stress test (CST).
Reactive nonstress test (NST).
Negative contraction stress test (CST).
Non-reactive nonstress test (NST).
The Correct Answer is B
Choice A rationale:
A positive contraction stress test (CST) indicates a potential problem with the fetal heart's response to uterine contractions, not spontaneous accelerations.
It's not consistent with the findings in this scenario.
Choice C rationale:
A negative CST would show no late decelerations in response to contractions, but it's not relevant here because contractions weren't induced.
Choice D rationale:
A non-reactive NST lacks the required accelerations, which are present in this case.
Choice B rationale:
Definition of reactive NST: A reactive NST is a reassuring fetal heart test that demonstrates a healthy fetal heart rate response to fetal movement. It's characterized by two or more fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting at least 15 seconds within a 20-minute period.
Significance of the findings: The presence of three accelerations measuring 15 bpm by 15 seconds within 20 minutes meets the criteria for a reactive NST. This suggests that the fetal nervous system is functioning well and responding appropriately to stimuli, indicating a healthy fetal heart rate pattern.
Nurse's reporting: The nurse should accurately report this finding to the provider as a "reactive nonstress test (NST)." This information is crucial for clinical decision-making regarding the ongoing management of the pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Diagnosing a fetus with a genetic disorder is outside the scope of practice for nurses. This task requires specialized training and expertise in genetics and diagnostic procedures, typically held by physicians such as geneticists, maternal-fetal medicine specialists, or genetic counselors.
Nurses play a crucial role in genetic counseling, but their responsibilities focus on:
Educating patients about genetic risks and testing options.
Obtaining informed consent for genetic testing.
Coordinating genetic testing appointments and procedures.
Providing emotional support and counseling to patients and families.
Facilitating communication between patients, families, and other healthcare providers.
Advocating for patients' rights and needs.
Choice B rationale:
Providing emotional support is a core component of nursing care, including genetic counseling. Nurses are trained to provide empathetic and compassionate support to patients and families who are facing the challenges of genetic conditions. This includes:
Active listening and validation of feelings.
Assisting with coping mechanisms and stress management.
Connecting patients with support groups and resources.
Promoting resilience and hope.
Choice C rationale:
Identifying at-risk families is a vital role for nurses in genetic counseling. By recognizing families with a history of genetic disorders or those who exhibit risk factors, nurses can initiate early intervention and preventive measures. This includes:
Taking a thorough family history.
Assessing risk factors and potential genetic concerns.
Educating families about their potential risks.
Referring families for genetic counseling and testing as appropriate.
Choice D rationale:
Collaboration with other healthcare providers and referral for specialized care are essential aspects of genetic counseling. Nurses often work within interdisciplinary teams to provide comprehensive care for patients with genetic concerns. This includes:
Communicating with geneticists, genetic counselors, and other specialists.
Coordinating referrals for genetic testing, counseling, and treatment.
Ensuring continuity of care across different healthcare settings.
Correct Answer is D
Explanation
Choice A rationale:
Fetal lung maturity is not assessed through chorionic villus sampling (CVS). It's primarily evaluated through amniocentesis, a different prenatal diagnostic procedure that involves sampling amniotic fluid.
CVS focuses on placental tissue, not lung development.
It's essential for clients to understand the specific purposes of each prenatal test to make informed decisions and have accurate expectations.
Choice B rationale:
While a non-stress test (NST) might be recommended after CVS in some cases, it's not a routine part of the procedure.
The decision to conduct an NST is based on individual risk factors and assessment by healthcare providers.
It's essential for clients to understand the potential need for additional testing but not assume it's always required.
Choice C rationale:
CVS is considered an invasive procedure, as it involves entering the uterus to collect placental tissue.
Non-invasive prenatal testing (NIPT) methods, which analyze fetal DNA in maternal blood, are available for screening purposes.
It's crucial for clients to differentiate between invasive and non-invasive prenatal testing options to make informed choices based on their preferences and risk factors.
Choice D rationale:
This statement accurately reflects the primary purpose of CVS.
It's a diagnostic procedure that can detect various genetic abnormalities, such as Down syndrome, cystic fibrosis, and TaySachs disease, during the first trimester of pregnancy.
Understanding the ability to detect genetic abnormalities early in pregnancy allows clients to make informed decisions about their pregnancy management and prepare for potential outcomes.
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