A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation.
The results of the test indicate a negative CST. Which of the following actions should the nurse take?
Repeat the CST in 20 min.
Administer an IV fluid bolus.
Prepare the client for cesarean birth.
Allow the labor to progress naturally.
Allow the labor to progress naturally.
The Correct Answer is D
Choice A rationale
Repeating the CST isn't necessary with a negative result, which indicates no significant uterine contractions affecting the fetus.
Choice B rationale
Administering an IV fluid bolus is not warranted by a negative CST result.
Choice C rationale
Preparing for a cesarean birth isn't necessary since a negative CST indicates no immediate fetal distress.
Choice D rationale
A negative CST indicates that there are no late decelerations, so the nurse should allow the labor to progress naturally.
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Correct Answer is B
Explanation
Choice A rationale
Meconium stools are common in newborns and not a concern in the context of weight loss.
Choice B rationale
Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.
Choice C rationale
Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.
Choice D rationale
Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.
Correct Answer is A
Explanation
Choice A rationale
Manifestations of shock might not appear until a client loses 20% of their blood volume. This is because the body compensates for blood loss by increasing heart rate and
vasoconstriction, maintaining blood pressure until a significant amount of blood is lost.
Choice B rationale
Hemorrhagic shock will cause a decrease, not an increase, in a client's serum pH due to the accumulation of lactic acid from anaerobic metabolism, leading to metabolic acidosis.
Choice C rationale
The most accurate indication of organ perfusion is a client's urine output. Adequate urine output reflects sufficient renal blood flow and overall perfusion, making it a reliable indicator
of organ perfusion.
Choice D rationale
An infusion of 1 mL of lactated Ringers for each 1 mL of blood loss is not accurate. The typical fluid replacement ratio is 3:, meaning 3 mL of crystalloid solution (like lactated Ringers) is given for each 1 mL of blood loss to account for fluid distribution in the body.