Nokea
The nurse is caring for the client in preterm labor who has gestational diabetes. The nurse determines that the client has a reactive NST when which findings are noted?
- A. Two fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) above baseline for at least 15 seconds in a 20-minute period
- B. An FHR acceleration of 15 bpm above baseline for at least 10 seconds in the 40-minute time period for the NST
- C. Two FHR accelerations of 20 bpm above baseline when the mother changes position during the 20-minute NST
- D. The occurrence of at least three mild repetitive variable decelerations in the 20-minute time period for the NST
Correct Answer: A
Rationale: The FHR is monitored by the placement of an electronic fetal monitor that has an ultrasound transducer to record the FHR and a tocodynamometer to detect uterine or fetal movement. The client is given a handheld marker to indicate when she feels fetal movement. Fetal movement is accompanied by an increase in the FHR in the healthy fetus. The criterion for a reactive (normal) NST is the presence of two FHR accelerations of 15 bpm above baseline lasting 15 seconds or longer in a 20-minute period. One FHR acceleration during a 40-minute period is insufficient and indicates a nonreactive (abnormal) NST. Maternal movement can cause an inconsistency in the FHR on the monitor strip and should be avoided during an NST. The occurrence of at least three mild repetitive variable decelerations in a 20-minute period describes a nonreactive (abnormal) NST and fetal intolerance.
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The nurse observes a sinusoidal FHR pattern on the monitor tracing. How should the nurse interpret this pattern?
- A. The fetus may be in a sleep state.
- B. Congenital anomalies are possible.
- C. This may indicate severe fetal anemia.
- D. This predicts normal fetal well-being.
Correct Answer: C
Rationale: A sinusoidal pattern, which is Drag and Drop, smooth, undulating, and uncommon, classically occurs with severe fetal anemia as a result of abnormal perinatal conditions. An FHR pattern having minimal variability (not a sinusoidal pattern) might indicate that the fetus is in a sleep state. Absent or minimal variability, not a sinusoidal FHR pattern, could indicate possible congenital anomalies. Moderate variability of the FHR (not a sinusoidal pattern) reflects normal fetal well-being.
How early in a pregnancy can the nurse expect to hear the fetal heartbeat using a Doppler device?
- A. 4 to 6 weeks
- B. 8 to 10 weeks
- C. 12 to 14 weeks
- D. 16 to 18 weeks
Correct Answer: C
Rationale: A fetal heartbeat can typically be detected by Doppler around 12-14 weeks, when the fetus is sufficiently developed.
The nurse is evaluating a breastfeeding session. The nurse determines that the infant has appropriately latched on to the mother’s breast when which observations are made? Select all that apply.
- A. The mother reports a firm tugging feeling on her nipple.
- B. A smacking sound is heard each time the baby sucks.
- C. The infant’s mouth covers only the mother’s nipple.
- D. The baby’s nose, mouth, and chin are touching the breast.
- E. The infant’s cheeks are rounded when sucking.
- F. The infant’s swallowing can be heard after sucking.
Correct Answer: A,D,E,F
Rationale: If the latch is correct, the mother should feel only a firm tugging and not pain or pinching when the infant sucks. A smacking or clicking noise heard when the infant sucks is an indication that the latch is incorrect and that the infant’s tongue may be inappropriately placed. Sucking only on the mother’s nipple will cause sore nipples, and milk will not be ejected from the milk ducts. When an infant is correctly latched to the breast, 2 to 3 centimeters (1/3 to 3/4 inch) of areola should be covered by the infant’s mouth. If this occurs, it will result in the infant’s nose, mouth, and chin touching the breast. When the infant is latched correctly, the cheeks will be rounded rather than dimpled. When the infant is latched correctly, the swallowing will be audible.
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
- A. The fetus is approximately 2 cm below maternal ischial spines.
- B. The cervix is totally dilated and effaced, with fetal engagement.
- C. The fetus is breech and posterior to the client’s pelvis.
- D. The fetal lie is transverse, and the fetal attitude is flexion.
Correct Answer: C
Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.