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A nurse is caring for a client at 38 weeks gestation who arrived to the triage with complaints of decreased fetal movement. The nurse contacts the provider and reports the findings. The nurse anticipates an order for which of the following?

A.

Non-stress test.

B.

Biophysical profile.

C.

Ultrasound.

D.

Amniocentesis.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

A non-stress test (NST) is a common initial assessment for decreased fetal movement. It evaluates fetal heart rate patterns in response to fetal movements, providing information about fetal well-being and oxygenation.

 

Choice B rationale

 

A biophysical profile (BPP) is a more comprehensive assessment that includes an NST and ultrasound evaluation of fetal movements, tone, breathing, and amniotic fluid volume. It may be ordered if the NST results are non-reassuring or if there are other concerns.

 

Choice C rationale

 

An ultrasound can provide valuable information about fetal growth, amniotic fluid volume, and placental function. It may be used in conjunction with other tests but is not the first-line assessment for decreased fetal movement.

 

Choice D rationale

 

Amniocentesis is an invasive procedure used for specific indications, such as genetic testing or assessing fetal lung maturity. It is not typically used for initial assessment of decreased fetal movement.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Category I tracings are considered normal and are associated with a well-oxygenated, non-acidotic fetus with a normal fetal heart rate baseline, moderate variability, and no late or variable decelerations. However, a baseline heart rate of 175 bpm is considered tachycardia, which does not fit the criteria for Category I.

Choice B rationale

Category II tracings are indeterminate and include any fetal heart rate pattern that does not fit into Category I or III. A baseline heart rate of 175 bpm with moderate variability and no accelerations or decelerations fits into this category. This indicates that the fetus may be experiencing some stress but is not in immediate danger.

Choice C rationale

Category III tracings are abnormal and are associated with an increased risk of fetal acidemia. These tracings include absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern. The given tracing does not meet these criteria as it shows moderate variability and no decelerations.

Choice D rationale

There is no Category IV in the classification of fetal heart rate tracings. The standard classification includes only Categories I, II, and III.

Correct Answer is B

Explanation

Choice A rationale

Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.

Choice B rationale

Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.

Choice C rationale

Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.

Choice D rationale

Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.

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