The nurse is caring for a client at 39 weeks gestation that arrived to OB triage with complaints of decreased fetal movement. The client was placed on external fetal monitors for an ordered non-stress test. The client was encouraged to drink some cold water and juice, as she reported she had not had anything to eat or drink yet for the day. The nurse observes the following tracing. How should the nurse document the non-stress test?

Choice A rationale

Cervical dilation and effacement indicate the body is preparing for labor by allowing the cervix to open and thin out for childbirth.

Choice B rationale

Swelling of the feet and ankles is common in pregnancy due to increased fluid retention but is not a specific sign of imminent labor.

Choice C rationale

The nesting instinct, a burst of energy and urge to prepare the home, often occurs as labor approaches, driven by hormonal changes.

Choice D rationale

Increase in maternal blood pressure may indicate preeclampsia, a pregnancy complication, but not a premonitory sign of labor.

Choice E rationale

Bloody show involves the discharge of mucus with blood from the cervix, signaling that labor is likely to begin soon.

Choice F rationale

Increase in Braxton Hicks contractions, or practice contractions, helps the uterus prepare for true labor by strengthening muscles.

Choice A rationale: Performing a sterile vaginal examination (SVE) is important for assessing cervical dilation and effacement, but it does not address the immediate concern of a Category 3 fetal heart rate tracing, which indicates fetal distress and requires prompt intervention.

Choice B rationale: Placing the client in a side-lying position can improve uteroplacental blood flow and oxygenation to the fetus by relieving compression on the inferior vena cava and enhancing venous return, thereby reducing fetal distress observed in Category 3 tracings.

Choice C rationale: Applying oxygen at 10 L/min via a venturi mask increases maternal oxygenation, which can enhance oxygen delivery to the fetus. This intervention is crucial in addressing fetal distress and improving fetal oxygenation, as observed in Category 3 fetal heart rate tracings.

Choice D rationale: Initiating a bolus of primary IV fluids can improve maternal blood volume and circulation, thereby enhancing uteroplacental perfusion and fetal oxygenation. This intervention is important in managing Category 3 fetal heart rate tracings and reducing fetal distress.

Choice E rationale: Increasing the oxytocin infusion to 13 mu/min is not appropriate as it can lead to hyperstimulation of the uterus, reducing uteroplacental blood flow and exacerbating fetal distress. In Category 3 tracings, the oxytocin infusion should be discontinued to reduce contractions.