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 ["A","C","D"]
Explanation
Choice A rationale
Delay in initiating breastfeeding can occur after a cesarean birth due to the effects of anesthesia, postoperative recovery, and the need for medical monitoring, which can delay the mother’s ability to start breastfeeding.
Choice B rationale
Routine use of intubation equipment is not standard practice during a cesarean birth. Intubation is typically reserved for patients who require general anesthesia or have complications that necessitate airway management.
Choice C rationale
The need for an indwelling urinary catheter is common during a cesarean birth. It helps to keep the bladder empty and out of the way during the procedure and is usually placed after anesthesia and removed shortly after the surgery.
Choice D rationale
Management of postpartum pain is an important topic to discuss with clients undergoing cesarean birth. Postoperative pain management may include medications and non-pharmacological methods to ensure comfort and aid in recovery.
Correct Answer is D
Explanation
Choice A rationale
Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.
Choice B rationale
Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.
Choice C rationale
Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.
Choice D rationale
Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.