A nurse is caring for a client who is having a nonstress test.
The fetal heart rate (FHR) baseline is 130 bpm, there is moderate variability, but there have been no accelerations or fetal movement.
Which of the following actions should the nurse complete next?
Encourage the client to walk around for 30 minutes, then resume monitoring.
Perform vibroacoustic stimulation.
Immediately report the situation to the provider and prepare the client for induction of labor.
Reposition the client into a supine position.
The Correct Answer is B
Choice A rationale
Encouraging the client to walk around for 30 minutes and then resume monitoring is not the most appropriate action in this scenario. Walking may help stimulate fetal movement, but it is not the first-line intervention when there are no accelerations or fetal movement during a nonstress test. The nurse should try other methods to stimulate fetal movement before resorting to walking.
Choice B rationale
Performing vibroacoustic stimulation is the correct action. Vibroacoustic stimulation involves using a device to produce a sound and vibration near the maternal abdomen to stimulate fetal movement and heart rate accelerations. This method is non-invasive and can help determine fetal well-being by eliciting a response from the fetus.
Choice C rationale
Immediately reporting the situation to the provider and preparing the client for induction of labor is premature. The absence of accelerations or fetal movement during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions, such as vibroacoustic stimulation, should be attempted first.
Choice D rationale
Repositioning the client into a supine position is not recommended. The supine position can lead to supine hypotensive syndrome, which can decrease blood flow to the fetus. The nurse should avoid placing the client in a supine position and instead try other methods to stimulate fetal movement.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale
Amniocentesis is a diagnostic test that involves extracting a small amount of amniotic fluid from the uterus to test for chromosomal abnormalities and genetic disorders. It is typically performed between 15 and 20 weeks of pregnancy. The fluid contains fetal cells and various chemicals produced by the baby, which can be analyzed to detect conditions such as Down syndrome, trisomy 18, and neural tube defects. This test is highly accurate and is often recommended when screening tests like the MSAFP indicate a potential issue.
Choice B rationale
A Nonstress Test (NST) is a non-invasive test that measures the fetal heart rate in response to its movements. It is used to assess fetal well-being, particularly in the third trimester, but it does not provide information about chromosomal abnormalities. The NST is typically used to monitor high-risk pregnancies and to ensure that the fetus is receiving enough oxygen.
Choice C rationale
A Biophysical Profile (BPP) combines an ultrasound with a Nonstress Test to evaluate the fetus’s health. It assesses fetal breathing movements, body movements, muscle tone, amniotic fluid volume, and heart rate reactivity. While it provides a comprehensive assessment of fetal well-being, it does not specifically diagnose chromosomal abnormalities. The BPP is often used in the third trimester to monitor high-risk pregnancies.
Choice D rationale
Chorionic Villus Sampling (CVS) is another diagnostic test that can detect chromosomal abnormalities and genetic disorders. It involves taking a small sample of placental tissue (chorionic villi) for analysis. CVS is typically performed between 10 and 13 weeks of pregnancy, earlier than amniocentesis. While it provides similar diagnostic information, it is not the test of choice following an abnormal MSAFP result, which is usually conducted later in pregnancy.