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.
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Correct Answer is C
Explanation
A. Stating that the healthcare provider left specific instructions may come across as confrontational and does not address the client's emotional state. The focus should be on empathetic communication rather than emphasizing authority.
B. While acknowledging the client’s feelings is important, this response may not de-escalate the situation. It focuses on the necessity of ambulation rather than addressing the client's anger and offering support.
C. Offering to return in 30 minutes provides the client with a sense of control and acknowledges their feelings. It is a supportive and respectful approach that allows time for the client to calm down and prepares them for ambulation.
D. Explaining that ambulation is necessary to avoid complications can sound directive and may not help in managing the client's anger. It is more effective to acknowledge the client's feelings and offer to help at a later time.
Correct Answer is B
Explanation
A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.
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