A pregnant woman comes in for her weekly fetal heart monitoring.
She is 35 weeks’ gestation.
After 20 minutes on the monitor, the fetal heart rate tracing shows 3 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 A
Choice A rationale:
A positive contraction stress test (CST) indicates that the fetal heart rate decelerates late in response to uterine contractions, suggesting potential uteroplacental insufficiency. However, the scenario does not describe a CST being performed, as it does not mention any assessment of uterine contractions or their relationship to fetal heart rate changes.
Choice C rationale:
A negative contraction stress test (CST) would demonstrate no late decelerations in response to contractions, suggesting adequate placental function. However, as mentioned earlier, a CST is not the test being performed in this scenario.
Choice D rationale:
A non-reactive nonstress test (NST) means that there were not enough fetal heart rate accelerations (at least 2, each lasting at least 15 seconds and peaking at least 15 beats above baseline) within a 20-minute period. This finding sometimes warrants further evaluation of fetal well-being. However, the scenario clearly states that 3 accelerations meeting the criteria for reactivity were observed.
Choice B rationale:
A reactive nonstress test (NST) is considered reassuring and indicates that the fetal heart rate is responding appropriately to fetal movement, suggesting that the fetus is likely healthy and well-oxygenated. The presence of 3 accelerations meeting the criteria for reactivity within a 20-minute period is the hallmark of a reactive NST.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hispanic women: While Hispanic cultures often emphasize strength and resilience, their expression of pain during labor can vary significantly. Some may vocalize their pain while others may remain more stoic. It's important to avoid generalizations and assess each individual's preferences and needs.
Choice B rationale:
Chinese women: In traditional Chinese culture, stoicism in the face of pain is often valued. This may be rooted in Confucianism, which emphasizes self-control and endurance. Women may be less likely to express their pain during labor to avoid appearing weak or losing face. They may also believe that vocalizing pain could negatively impact the birthing process. However, as labor progresses, they may become more vocal and request pain relief.
Choice C rationale:
Caucasian/European women: Caucasian women exhibit diverse responses to labor pain, influenced by personal experiences, cultural beliefs, and social expectations. Some may express their pain openly, while others may prefer to manage it quietly. It's crucial to avoid stereotyping and provide individualized care.
Choice D rationale:
African-American women: African-American women often express their pain during labor more openly than some other cultural groups. This may be due to historical experiences of racism and discrimination in healthcare, leading to a distrust of medical professionals and a greater reliance on self-advocacy. They may also have a stronger sense of community and support networks that encourage open expression of pain.
Correct Answer is B
Explanation
Choice A rationale:
Performing a vaginal exam is not the priority intervention for a client experiencing hypotension after an epidural. While a vaginal exam may be necessary to assess cervical dilation and fetal station, it does not address the underlying cause of the client's hypotension.
Additionally, a vaginal exam could potentially worsen the client's hypotension by stimulating the vagus nerve, which can lead to decreased heart rate and blood pressure.
Therefore, it is not the most appropriate initial response in this situation.
Choice B rationale:
Turning the client onto her side is the most appropriate initial response to hypotension after an epidural. This position helps to increase venous return to the heart, which can improve cardiac output and blood pressure.
It also helps to prevent aortocaval compression, which can occur when the pregnant uterus compresses the inferior vena cava, reducing blood flow back to the heart.
By turning the client onto her side, the nurse can quickly and easily address the underlying cause of the hypotension and help to improve the client's hemodynamic status.
Choice C rationale:
Catheterizing the client may be necessary if the client is unable to void spontaneously, but it is not the priority intervention for hypotension after an epidural.
Urinary retention can occur after an epidural, but it is not typically the cause of hypotension in this setting.
Therefore, catheterization would not be the most appropriate initial response.
Choice D rationale:
Decreasing the IV fluid rate may be necessary if the client is experiencing fluid overload, but it is not the priority intervention for hypotension after an epidural.
In fact, decreasing the IV fluid rate could potentially worsen the hypotension by reducing the circulating blood volume.
Therefore, it is not the most appropriate initial response.
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