QUESTION: 101

A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:

Nonreactive
Reactive
Positive
Negative

Answer(s): B

Explanation:

(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.

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QUESTION: 101

A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:

Nonreactive
Reactive
Positive
Negative

Answer(s): B

Explanation:

(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.

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QUESTION: 102

The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 12 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:

Maintain client's privacy.
Assist with assessment procedures.
Provide strategies to maintain client control.
Enlist additional caregiver support to ensure client's safety.

Answer(s): C

Explanation:

(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client's ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.

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QUESTION: 102

The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 12 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:

Maintain client's privacy.
Assist with assessment procedures.
Provide strategies to maintain client control.
Enlist additional caregiver support to ensure client's safety.

Answer(s): C

Explanation:

(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client's ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.

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QUESTION: 101

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QUESTION: 101

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QUESTION: 102

Explanation:

QUESTION: 102

Explanation:

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