A pregnant woman's biophysical profile (BPP) score is 8. She asks the nurse to explain the results. How should the nurse respond initially?
"Further testing will be performed to determine the meaning of this score."
"An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding delivery."
"Immediate delivery by cesarean birth is being considered."
"The test results are within normal limits."
The Correct Answer is D
A. Suggesting that further testing is needed implies that the score is abnormal or inconclusive. A BPP score of 8 out of 10 is generally considered normal, indicating that the fetus is well-oxygenated and not showing signs of compromise, so immediate further testing is not indicated.
B. While an obstetric specialist may review BPP results as part of routine care, the nurse should first provide accurate, reassuring information about the score. This response could cause unnecessary anxiety.
C. Immediate delivery by cesarean is not indicated for a BPP score of 8. Cesarean delivery is usually considered for scores of 4 or less, which indicate significant fetal compromise.
D. The test results are within normal limits is correct. A BPP evaluates fetal breathing movements, body movements, muscle tone, amniotic fluid volume, and nonstress test results, each scored 0–2. A total of 8–10 indicates a healthy fetus with no evidence of acute distress. This response reassures the client and accurately reflects the meaning of her BPP score.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Burping the infant during and after feeding is an important practice to release swallowed air, reduce discomfort, and prevent spitting up or gas. Burping as needed and during natural pauses in feeding demonstrates proper technique and understanding of infant feeding safety and comfort, indicating correct learning.
B. Adding rice cereal to formula at 2 weeks of age is not recommended. Early introduction of solids or thickened formula can increase the risk of aspiration, overfeeding, and gastrointestinal complications. Solid foods are generally introduced at about 4–6 months of age when the infant is developmentally ready.
C. Warming a bottle in a microwave oven is unsafe. Microwaves can cause uneven heating and “hot spots”, which may burn the infant’s mouth or throat. Safe warming methods include placing the bottle in warm water or using a bottle warmer.
D. Refrigerating leftover formula for the next feeding is inappropriate. Prepared formula should be used within 1–2 hours of feeding, and any leftover milk or formula from a feeding should be discarded to prevent bacterial growth and potential infection.
Correct Answer is C
Explanation
A. Eliciting the Moro reflex to wake the baby is unsafe and unnecessary. This method involves startling the infant, which can cause distress and may result in injury to the nipple, infant’s gums, or palate. It does not address the correct technique for breaking suction safely.
B. Pulling the breast or nipple directly from the baby’s mouth can lead to significant nipple trauma, including cracking, bleeding, and pain, and may also injure the infant’s mouth. This method is considered unsafe and is strongly discouraged in breastfeeding education.
C. Breaking the suction by gently inserting a clean finger into the corner of the infant’s mouth is the recommended technique. This action releases the latch safely, prevents nipple trauma, and allows the infant to unlatch without discomfort. It ensures that both the mother and baby remain safe during breastfeeding, and it supports proper feeding practices.
D. Relying on a popping sound as an indicator of safe breast removal is unreliable and can be misleading. Attempting to remove the breast based on sound alone may result in abrupt or forceful removal, causing pain or injury to the mother’s nipple and the infant’s oral tissues.
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