The nurse is caring for a client at 39 weeks gestation who arrived to OB triage with a complaint 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.

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 results?

Reactive.

Non-reactive.

Inconclusive.

Positive.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A reactive non-stress test (NST) indicates that the fetal heart rate increases appropriately with fetal movements, suggesting good fetal oxygenation and neurological function. This is the desired outcome for an NST4.
Choice B rationale
A non-reactive NST means the fetal heart rate did not increase with movements, which could indicate fetal hypoxia or other issues. Further testing would be needed to assess fetal well-being.
Choice C rationale
An inconclusive NST means the test did not provide enough information to determine fetal well-being, possibly due to fetal sleep cycles or maternal factors. Additional testing would be required.
Choice D rationale
A positive NST is not a standard term used in fetal monitoring. The correct terms are reactive or non-reactive.

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Correct Answer is A

Explanation

Choice A rationale
Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.
Choice B rationale
Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.
Choice C rationale
Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.
Choice D rationale
Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.

A. Encourage the client to walk around for 30 minutes, then resume monitoring. B. Perform vibroacoustic stimulation. C. Immediately report the situation to the provider and prepare the client for induction of labor. D. Reposition the client into a supine position.

Correct Answer is B

Explanation

Choice A rationale
Encouraging the client to walk around for 30 minutes and then resume monitoring is not the most appropriate action in this scenario. Walking may help stimulate fetal movement, but it is not the first-line intervention when there are no accelerations or fetal movement during a nonstress test. The nurse should try other methods to stimulate fetal movement before resorting to walking.
Choice B rationale
Performing vibroacoustic stimulation is the correct action. Vibroacoustic stimulation involves using a device to produce a sound and vibration near the maternal abdomen to stimulate fetal movement and heart rate accelerations. This method is non-invasive and can help determine fetal well-being by eliciting a response from the fetus.
Choice C rationale
Immediately reporting the situation to the provider and preparing the client for induction of labor is premature. The absence of accelerations or fetal movement during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions, such as vibroacoustic stimulation, should be attempted first.
Choice D rationale
Repositioning the client into a supine position is not recommended. The supine position can lead to supine hypotensive syndrome, which can decrease blood flow to the fetus. The nurse should avoid placing the client in a supine position and instead try other methods to stimulate fetal movement.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is pregnant. The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?

Correct Answer is A

Explanation

A nurse is caring for a client who is having a nonstress test. The fetal heart rate (FHR) baseline is 130 bpm, there is moderate variability, but there have been no accelerations or fetal movement. Which of the following actions should the nurse complete next?

Correct Answer is B

Explanation

The OB provider is concerned about placental perfusion and intrauterine growth restriction (IUGR) after noting minimal fetal growth over the past month. What non-invasive antenatal test would the nurse anticipate the provider will order?

The nurse observes variable decelerations on the fetal monitor tracing. Which of the following is a correct interpretation of this finding?

A nurse is creating the plan of care for a client in active labor. Which of the following actions should the nurse include in the plan of care?

A client has received MSAFP test result. The client is requesting additional testing to determine whether the fetus has a chromosomal abnormality. Which of the following antenatal tests would the nurse anticipate the provider will order?

A client who is 32 weeks gestation and has gestational diabetes calls the provider’s office to report decreased fetal movement over the last several hours. The provider advises her to report to OB triage for further testing. What test should you anticipate the provider will order?

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client’s umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

The labor and delivery nurse is caring for a client in active labor. The nurse notes the fetal heart rate baseline is 175 bpm, moderate variability, accelerations are absent and no decelerations noted. How should the nurse describe this tracing to the medical provider?