During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?
Acceleration.
Nonreactive pattern.
Fetal movement.
Positive tracing.
The Correct Answer is A
A. Acceleration refers to a temporary increase in the fetal heart rate of at least 15 beats per minute above the baseline for at least 10 seconds. The observation of the fetal heart rate increasing 15 beats above baseline twice during the test indicates that accelerations are present, which is a reassuring sign of fetal well-being.
B. A nonreactive pattern would indicate that the test did not meet the criteria for accelerations or fetal heart rate reactivity, which is not the case here as the fetal heart rate did exhibit accelerations.
C. Fetal movement could contribute to accelerations but is not the term used to describe the findings of the test itself. The specific observation made was an increase in fetal heart rate, which is classified as an acceleration.
D. A positive tracing indicates that the nonstress test met criteria for fetal well-being, typically with at least two accelerations, but the correct term for the specific observation here is acceleration rather than describing the overall result.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Palpating the brachial artery before inflating the blood pressure cuff is a correct technique to locate the artery and ensure accurate blood pressure measurement.
B. Counting respirations while palpating the radial pulse is a correct technique as it minimizes the risk of the client altering their breathing pattern.
C. Asking the client to relax their arm before taking the blood pressure is an appropriate step to ensure an accurate measurement.
D. Inserting a thermometer into the sublingual pocket after the client sips water can affect the accuracy of the temperature reading, as water can alter the temperature measurement.
Correct Answer is B
Explanation
A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.
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