For a woman at 42 weeks gestation, which finding would require more assessment by the nurse?

Fetal heart rate of 118 beats/min

One fetal movement noted in a two-hour assessment by the mother

Cervix dilated 2 cm and 50% effaced

Score of 8 on the biophysical profile

Answer and Explanation

The Correct Answer is B

A. Fetal heart rate of 118 beats/min. A fetal heart rate of 118 bpm is within the normal range of 110-160 bpm and does not necessarily indicate fetal distress. While continuous monitoring is important in post-term pregnancies, this finding alone does not require urgent assessment.

B. One fetal movement noted in a two-hour assessment by the mother. Decreased fetal movement is a concerning sign that requires further assessment. At 42 weeks gestation, the aging placenta may lead to reduced oxygen and nutrient supply, increasing the risk of fetal compromise. Normally, at least 10 movements should be felt within two hours. A significant decrease in movement could indicate fetal distress or hypoxia, requiring immediate evaluation with a non-stress test (NST) or biophysical profile (BPP).

C. Cervix dilated 2 cm and 50% effaced. A partially dilated and effaced cervix is expected in a post-term pregnancy and does not indicate fetal distress. It suggests that labor may be approaching but does not require additional urgent assessment.

D. Score of 8 on the biophysical profile. A biophysical profile (BPP) score of 8 out of 10 is reassuring and indicates normal fetal well-being. If the score were 4 or lower, it would require immediate intervention, but a score of 8 suggests adequate oxygenation and fetal health.

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Correct Answer is D

Explanation

A. Correct coagulation failure by giving platelets. Anaphylactoid syndrome of pregnancy (amniotic fluid embolism) can cause disseminated intravascular coagulation (DIC), but correcting coagulation abnormalities is not the immediate priority. The first intervention should focus on oxygenation and stabilizing the cardiovascular system.

B. Provide emotional support to the woman and her family. While emotional support is important, this is not the priority in a life-threatening emergency. The focus should be on immediate resuscitation efforts to prevent maternal and fetal death.

C. Maintain cardiac output and assess intake & output. Maintaining cardiac output is critical, but this is secondary to oxygenation. The initial response should be administering high-flow oxygen to improve maternal and fetal oxygenation before managing hemodynamic stability.

D. Administer oxygen by tight face mask 8-10L/min. Amniotic fluid embolism causes sudden respiratory distress, hypoxia, and cardiovascular collapse. Immediate high-flow oxygen delivery is the first and most critical intervention to improve oxygenation, support cardiac function, and prevent further complications.

A. True B. False

Correct Answer is A

Explanation

Professor Proctor emphasizes safety as the highest priority while traveling, including when coming to class. Ensuring that students arrive safely is considered more important than strict punctuality.

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For a woman at 42 weeks gestation, which finding would require more assessment by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

If the nurse suspects a patient has experienced anaphylactoid syndrome of pregnancy (amniotic fluid embolus), which of the following is the priority nursing intervention?

Correct Answer is D

Explanation

Professor Proctor: Always wants us to be safe while traveling anywhere- especially when coming to class. This is prioritized even over being on time.

Correct Answer is A

Explanation

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