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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?

A.

Encourage the client to walk around for 30 minutes, then resume monitoring.

B.

Perform vibroacoustic stimulation.

C.

Immediately report the situation to the provider and prepare the client for induction of labor.

D.

Reposition the client into a supine position.

Answer and Explanation

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 A

Explanation

Choice A rationale

This statement is incorrect. Vagus nerve stimulation actually decreases FHR variability. The vagus nerve, part of the parasympathetic nervous system, slows the heart rate and reduces variability.

Choice B rationale

This statement is correct. Baroreceptors are sensors located in blood vessels that help regulate blood pressure by detecting changes in the stretch of the vessel walls. They play a crucial role in maintaining stable blood pressure levels.

Choice C rationale

This statement is correct. The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, controls the fetal heart rate. It regulates the balance between heart rate acceleration and deceleration.

Choice D rationale

This statement is correct. Chemoreceptors respond to changes in blood gas levels, such as oxygen and carbon dioxide. They help regulate respiratory and cardiovascular responses to maintain homeostasis.

Correct Answer is A

Explanation

Choice A rationale

The “Passenger” refers to the fetus and its position, size, and presentation. In this case, the fetus has an estimated weight of 9 lbs and is in the left occiput posterior (LOP) position. These factors can complicate labor by making it more difficult for the fetus to navigate through the birth canal, potentially leading to prolonged labor and increased risk of interventions.

Choice B rationale

The “Passage” refers to the birth canal, including the pelvis and soft tissues. While the passage is an important factor in labor, the primary concern in this scenario is the size and position of the fetus, which falls under the “Passenger” category.

Choice C rationale

The “Powers” refer to the strength and frequency of uterine contractions. Although the patient is having contractions every 3 minutes, the main concern here is the fetal size and position, which are more directly related to the "Passenger"4.

Choice D rationale

The “Psyche” refers to the psychological state of the mother, including her stress levels and emotional well-being. While important, the primary concern in this scenario is the physical factors related to the fetus, which are categorized under the "Passenger"4.

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