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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

A reactive non-stress test (NST) indicates that the fetal heart rate increases appropriately with fetal movements, suggesting good fetal oxygenation and neurological function. This is the desired outcome for an NST4.

Choice B rationale

A non-reactive NST means the fetal heart rate did not increase with movements, which could indicate fetal hypoxia or other issues. Further testing would be needed to assess fetal well-being.

Choice C rationale

An inconclusive NST means the test did not provide enough information to determine fetal well-being, possibly due to fetal sleep cycles or maternal factors. Additional testing would be required.

Choice D rationale

A positive NST is not a standard term used in fetal monitoring. The correct terms are reactive or non-reactive.

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.

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