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.
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View Related questions
Correct Answer is B
Explanation
Choice A rationale
The presenting part being 2 cm below the ischial spines would be documented as +2 station, indicating that the fetal head is descending well into the pelvis.
Choice B rationale
The presenting part being 2 cm above the ischial spines is correctly documented as -2 station. This indicates that the fetal head is still relatively high in the pelvis and has not yet descended to the level of the ischial spines.
Choice C rationale
The presenting part being at the level of the ischial spines is documented as 0 station. This is the midpoint of the pelvis and indicates that the fetal head is engaged.
Choice D rationale
The presenting part being 2 cm below the cervix is not a standard way to describe fetal station. Station is measured relative to the ischial spines, not the cervix.
Correct Answer is A
Explanation
Choice A rationale
Breech presentation means the fetus’s buttocks or feet are positioned to be delivered first. Fetal heart tones are often heard above the umbilicus in this position.
Choice B rationale
Transverse lie means the fetus is lying horizontally in the uterus. Fetal heart tones would typically be heard at the sides of the abdomen.
Choice C rationale
Cephalic presentation means the fetus’s head is positioned to be delivered first. Fetal heart tones are usually heard below the umbilicus in this position.
Choice D rationale
Oblique lie means the fetus is positioned diagonally in the uterus. Fetal heart tones can be variable depending on the exact position.