Nokea
What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?
- A. Positive
- B. Negative
- C. Reactive
- D. Nonreactive
Correct Answer: C
Rationale: The correct answer is C: Reactive. In a nonstress test, a reactive result is considered normal and indicates a healthy fetus. This is because it shows two or more fetal heart rate accelerations of 15 or more BPM with fetal movement in a 20-minute period, which signifies a responsive and healthy fetal heart rate pattern. The other choices are incorrect because:
A: Positive typically indicates a concerning result in medical contexts.
B: Negative signifies an abnormal result in this context.
D: Nonreactive suggests a lack of desired fetal heart rate accelerations with movement, which is not ideal.
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A biophysical profile is performed on a pregnant patient. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. Which answer would be the correct interpretation of this test result?
- A. A score of 10 would indicate that the results are equivocal.
- B. A score of 8 would indicate normal results.
- C. A score of 6 would indicate that birth should be considered as a possible treatment option.
- D. A score of 9 would indicate reassurance.
Correct Answer: B
Rationale: The correct answer is B: A score of 8 would indicate normal results. In a biophysical profile, each component is scored as either 0 or 2, totaling a maximum of 10. In this case, the patient has: 0 for NST, 2 for FBMs, 1 for gross movements, 2 for fetal tone, and 2 for AFI, totaling 7. However, if there are at least 2 episodes of FBMs, this component is given a score of 2. Therefore, the correct total score is 8. This score indicates normal results, as it meets the criteria for a reassuring biophysical profile.
Incorrect Choices:
A: A score of 10 would indicate that the results are equivocal - This is incorrect as a score of 10 would indicate normal results, not equivocal.
C: A score of 6 would indicate that birth should be considered as a possible treatment option - This is incorrect, as a score
A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, “I think I am engorged. My breasts are very hard and hot and they really hurt.” Which of the following questions should the nurse ask at this time?
- A. “Have you taken a warm shower this morning?”
- B. “Do you have an electric breast pump?”
- C. “How much did you have to drink yesterday?”
- D. “When was the last time you fed the baby?”
Correct Answer: D
Rationale: Asking when the client last fed the baby helps determine if engorgement is due to infrequent feeding, which is a common cause of breast engorgement.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.
A breastfeeding client asks the nurse to make sure that her newborn is positioned and latched well at the breast. Which of the following assessments would indicate that the baby is poorly latched?
- A. The baby swallows after every suckle.
- B. The baby’s body is facing the mother’s body.
- C. The baby’s lower lip is curled under.
- D. The baby is lying at the level of the mother’s breasts.
Correct Answer: C
Rationale: A curled-under lower lip indicates poor latching, which can lead to ineffective feeding and nipple damage.
The nurse is completing the family assessment on a patient at 10 weeks of gestation. What data are included in the family assessment? Select all that apply.
- A. annual income
- B. total number of cousins
- C. number of people living in the household
- D. person in the household who makes the major decisions for the family
Correct Answer: A
Rationale: The correct answer is A: annual income. This data is crucial for assessing the family's financial resources and potential impact on the patient's health and well-being during pregnancy. Annual income can help identify possible financial stressors that may affect access to healthcare, nutrition, and overall prenatal care.
B: Total number of cousins is not typically part of a family assessment during pregnancy and does not directly impact the patient's prenatal care.
C: Number of people living in the household is important for understanding the household dynamics, but it may not be directly related to the patient's prenatal care needs.
D: Identifying the person in the household who makes major decisions is important for understanding family dynamics, but it may not directly impact the patient's prenatal care.