A nurse is educating a client about a contraction stress test.
Which of the following is correct regarding the contraction stress test?
We are looking for a negative result.
We are looking for three contractions in a 10-minute period with moderate variability and no decelerations.
A negative result indicates fetal well-being.
A positive result indicates fetal growth restriction, lower Apgar scores, and need for cesarean delivery.
The Correct Answer is C
Choice A rationale
While a negative result in a Contraction Stress Test (CST) is desirable, this choice does not fully explain the significance of the result. A negative CST indicates that there are no late decelerations in the fetal heart rate in response to uterine contractions, suggesting that the fetus can handle the stress of labor.
Choice B rationale
This choice describes the criteria for a reactive Nonstress Test (NST), not a Contraction Stress Test (CST). In a CST, the focus is on the fetal heart rate response to contractions, not the number of contractions or variability.
Choice C rationale
A negative result in a CST indicates fetal well-being, meaning that the fetus can tolerate the stress of uterine contractions without showing signs of distress, such as late decelerations in the heart rate. This result suggests that the fetus is likely to handle labor well.
Choice D rationale
A positive result in a CST indicates that the fetus has late decelerations in response to contractions, which can be a sign of fetal distress. This result may suggest fetal growth restriction, lower Apgar scores, and the potential need for cesarean delivery. However, this choice does not fully capture the significance of a positive CST result.
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Correct Answer is B
Explanation
Choice A rationale
Monitoring the patient’s vocalizations and facial expressions can provide some information about the intensity of contractions, but it is subjective and not a reliable method for accurately assessing contraction intensity.
Choice B rationale
Palpating the maternal abdomen during a contraction is the best method for determining the intensity of contractions. By feeling the firmness of the uterus, the nurse can assess whether the contractions are mild, moderate, or strong. This method provides a more objective measure of contraction intensity compared to other methods.
Choice C rationale
Timing the amount of time between the ending of one contraction and the beginning of the next provides information about the frequency of contractions, not their intensity. This choice does not address the question of how to determine contraction intensity.
Choice D rationale
Palpating the maternal abdomen right after a contraction does not provide information about the intensity of the contraction that just occurred. The uterus will be relaxed after the contraction, making it difficult to assess the strength of the previous contraction.
Correct Answer is A
Explanation
Choice A rationale
Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.
Choice B rationale
Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.
Choice C rationale
Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.
Choice D rationale
Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.