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A nurse is educating a client about a contraction stress test.

Which of the following is correct regarding the contraction stress test?

A.

We are looking for a negative result.

B.

We are looking for three contractions in a 10-minute period with moderate variability and no decelerations.

C.

A negative result indicates fetal well-being.

D.

A positive result indicates fetal growth restriction, lower Apgar scores, and need for cesarean delivery.

Answer and Explanation

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 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.

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.

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