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 A
Explanation
Choice A rationale
This statement is incorrect because Stage 2 of labor does not involve the delivery of the placenta. Stage 2 starts with the complete dilation and effacement of the cervix and ends with the delivery of the fetus. The delivery of the placenta occurs in Stage 3 of labor.
Choice B rationale
This statement is correct. Stage 2 of labor begins with complete effacement and dilation of the cervix. This stage is characterized by the mother pushing and the eventual delivery of the baby.
Choice C rationale
This statement is also correct. Stage 2 starts when the cervix is fully dilated, allowing the mother to start pushing. This stage continues until the baby is born.
Choice D rationale
This statement is incorrect. Stage 2 ends with the delivery of the fetus, not the placenta. The delivery of the placenta is part of Stage 3 of labor.
Correct Answer is B
Explanation
Choice A rationale
Magnetic Resonance Imaging (MRI) is a non-invasive imaging technique that provides detailed images of the fetus and placenta. However, it is not typically used as the first-line test for assessing placental perfusion and IUGR. Doppler flow studies are more specific for evaluating blood flow and detecting issues related to placental insufficiency.
Choice B rationale
Doppler flow studies are non-invasive tests that assess blood flow in the umbilical artery and other fetal vessels. These studies are particularly useful in evaluating placental perfusion and identifying intrauterine growth restriction (IUGR). Abnormal Doppler flow patterns can indicate compromised blood flow to the fetus, which is a concern in cases of minimal fetal growth.
Choice C rationale
Amniocentesis is an invasive procedure that involves extracting a sample of amniotic fluid for genetic testing and assessment of fetal lung maturity. It is not used for evaluating placental perfusion or IUGR7.
Choice D rationale
Chorionic villus sampling (CVS) is an invasive procedure used for early genetic testing by sampling placental tissue. It is not used for assessing placental perfusion or IUGR7.