The nurse is teaching a pregnant client about fetal kick counts.
Which statement made by the client indicates a need for further instruction?

Choice A rationale:

Epicanthal folds: These are skin folds that cover the inner corners of the eyes. They are a common characteristic of Trisomy 21, also known as Down syndrome.

Heart murmur: A heart murmur is an abnormal sound heard during a heartbeat. It can be caused by a variety of conditions, including Trisomy 21. Approximately half of babies with Down syndrome have a heart defect.

Low-set ears: This means that the ears are positioned lower on the head than usual. This is another common characteristic of Trisomy 21.

Poor muscle tone: This means that the muscles are weak and floppy. This is also a common characteristic of Trisomy 21.

Choice B rationale:

Cystic fibrosis: This is a genetic disorder that affects the lungs and digestive system. It is not typically associated with the physical features observed in this newborn. Newborns with cystic fibrosis typically present with meconium ileus, failure to thrive, and recurrent respiratory infections.

Choice C rationale:

Tay-Sachs disease: This is a rare genetic disorder that affects the nervous system. It is not typically associated with the physical features observed in this newborn. Infants with Tay-Sachs disease typically appear normal at birth, with symptoms developing around 6 months of age. These symptoms can include developmental delays, muscle weakness, seizures, and blindness.

Choice D rationale:

Marfan syndrome: This is a genetic disorder that affects the connective tissue. It is not typically associated with the physical features observed in this newborn. Individuals with Marfan syndrome typically have tall stature, long limbs, and hypermobile joints. They may also have eye problems, such as lens dislocation, and heart problems, such as aortic aneurysm.

Choice A rationale:

A positive contraction stress test (CST) indicates that the fetal heart rate decelerates late in response to uterine contractions, suggesting potential uteroplacental insufficiency. However, the scenario does not describe a CST being performed, as it does not mention any assessment of uterine contractions or their relationship to fetal heart rate changes.

Choice C rationale:

A negative contraction stress test (CST) would demonstrate no late decelerations in response to contractions, suggesting adequate placental function. However, as mentioned earlier, a CST is not the test being performed in this scenario.

Choice D rationale:

A non-reactive nonstress test (NST) means that there were not enough fetal heart rate accelerations (at least 2, each lasting at least 15 seconds and peaking at least 15 beats above baseline) within a 20-minute period. This finding sometimes warrants further evaluation of fetal well-being. However, the scenario clearly states that 3 accelerations meeting the criteria for reactivity were observed.

Choice B rationale:

A reactive nonstress test (NST) is considered reassuring and indicates that the fetal heart rate is responding appropriately to fetal movement, suggesting that the fetus is likely healthy and well-oxygenated. The presence of 3 accelerations meeting the criteria for reactivity within a 20-minute period is the hallmark of a reactive NST.