The nurse is reading the results of non-stress test (NST) strips completed that day. Which of the following strips meets the criteria for a reactive NST? Select one:

A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes.

A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes.

A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes.

A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes.

Answer and Explanation

The Correct Answer is B

Choice A Reason: A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. A non-reactive NST may suggest fetal hypoxia, distress, or sleep, but it does not necessarily indicate a problem. A non-reactive NST may require further testing or stimulation to elicit a reactive result.

Choice B Reason A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. This is because this strip meets the criteria for a reactive NST, which is a non-invasive test that evaluates fetal well- being and oxygenation by measuring the fetal heart rate response to fetal movements. A reactive NST is defined as having at least two accelerations of the fetal heart rate that are at least 15 beats per minute above the baseline and last for at least 15 seconds within a 20-minute period.

Choice C Reason: A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in amplitude, as they are only 5 beats per minute above the baseline, instead of at least 15 beats per minute.

Choice D Reason: A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in duration, as they last only for 10 seconds, instead of at least 15 seconds.

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Correct Answer is A

Explanation

Choice A Reason: Inspecting the placenta after delivery for intactness. This is because inspecting the placenta after delivery for intactness is a nursing intervention that can prevent late postpartum hemorrhage, which is excessive bleeding from the uterus or genital tract that occurs more than 24 hours but less than 12 weeks after delivery. Late postpartum hemorrhage can be caused by retained placental fragments, subinvolution of the uterus, infection, or coagulation disorders. Inspecting the placenta after delivery for intactness can help identify and remove any retained placental fragments that may interfere with uterine contraction and involution, which are essential for hemostasis.

Choice B Reason: Manually removing the placenta at delivery. This is an incorrect answer that indicates an inappropriate and risky intervention that can cause late postpartum hemorrhage. Manually removing the placenta at delivery is a procedure that involves inserting a hand into the uterus and detaching the placenta from the uterine wall. Manually removing the placenta at delivery is indicated only for a retained or adherent placenta that does not separate spontaneously or with gentle traction within 30 minutes after delivery. Manually removing the placenta at delivery can cause trauma, infection, or incomplete removal of the placenta, which can increase the risk of late postpartum hemorrhage.

Choice C Reason: Administering broad-spectrum antibiotics prophylactically. This is an incorrect answer that suggests an unnecessary and ineﬀective intervention that can prevent late postpartum hemorrhage. Administering broad- spectrum antibiotics prophylactically is a pharmacological intervention that involves giving antibiotics to prevent or treat infection. Administering broad-spectrum antibiotics prophylactically is indicated for women with risk factors or signs of infection during or after delivery, such as prolonged rupture of membranes, chorioamnionitis, fever, or foul- smelling lochia. Administering broad-spectrum antibiotics prophylactically may reduce the risk of infection-related late postpartum hemorrhage, but it does not address other causes of late postpartum hemorrhage such as retained placental fragments or subinvolution of the uterus.

Choice D Reason: Applying traction on the umbilical cord to speed up separation of the placenta. This is an incorrect answer that refers to a diﬀerent intervention that can prevent early postpartum hemorrhage, not late postpartum hemorrhage. Applying traction on the umbilical cord to speed up separation of the placenta is a technique that involves pulling on the umbilical cord while applying counter pressure on the uterus to facilitate placental expulsion. Applying traction on the umbilical cord to speed up separation of the placenta is indicated for active management of the third stage of labor, which can prevent early postpartum hemorrhage, which is excessive bleeding from the uterus or genital tract that occurs within 24 hours after delivery. Early postpartum hemorrhage can be caused by uterine atony, retained placenta, lacerations, or coagulation disorders.

A. Daily weight. B. Consistency of stool. C. Volume of urine output. D. Blood pH.

Correct Answer is D

Explanation

Choice A Reason: Daily weight. This is an incorrect answer that indicates a valid parameter to assess hydration status. Daily weight is a measure of the body mass that can reﬂect changes in ﬂuid balance. Daily weight can help detect ﬂuid loss or gain in premature infants, who are more prone to dehydration or overhydration due to immature renal function and high insensible water loss.

Choice B Reason: Consistency of stool. This is an incorrect answer that indicates a valid parameter to assess hydration status. Consistency of stool is a measure of the texture and form of feces that can reﬂect changes in ﬂuid intake and absorption. Consistency of stool can help identify diarrhea or constipation in premature infants, who are more susceptible to gastrointestinal problems such as necrotizing enterocolitis or feeding intolerance.

Choice C Reason: Volume of urine output. This is an incorrect answer that indicates a valid parameter to assess hydration status. Volume of urine output is a measure of the amount of urine produced and excreted by the kidneys that can reﬂect changes in ﬂuid balance and renal function. Volume of urine output can help monitor hydration status and kidney function in premature infants, who are more vulnerable to ﬂuid overload or deficit and renal impairment.

Choice D Reason: Blood pH. This is because blood pH is a measure of the acidity or alkalinity of the blood, which reﬂects the balance between carbon dioxide and bicarbonate in the body. Blood pH is not a direct indicator of hydration status, which refers to the amount of water and electrolytes in the body. Hydration status can aﬀect blood pH, but blood pH can also be inﬂuenced by other factors such as respiratory or metabolic disorders.

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The nurse is reading the results of non-stress test (NST) strips completed that day. Which of the following strips meets the criteria for a reactive NST? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

In caring for the premature infant, the nurse must continually assess hydration status. Parameters to assess would include all of the following except: Select one:

Correct Answer is D

Explanation

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