A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation.
Which of the following findings indicates a reactive nonstress test?
Fetal heart rate (FHR) accelerations occur with fetal movement.
Late decelerations of the FHR occur with contractions.
Variable decelerations of the FHR.
FHR pattern with minimal variability.
The Correct Answer is A
Choice A rationale
Fetal heart rate (FHR) accelerations with fetal movement are a sign of a healthy and reactive nonstress test. This indicates that the fetus is well-oxygenated and there is no immediate distress.
Choice B rationale
Late decelerations of the FHR occur with contractions and are a concern for fetal hypoxia. This does not indicate a reactive nonstress test and instead suggests the need for further evaluation.
Choice C rationale
Variable decelerations are abrupt decreases in FHR and could indicate umbilical cord compression. This does not correlate with a reactive nonstress test.
Choice D rationale
FHR pattern with minimal variability can be a sign of fetal distress or compromised oxygenation. It is not indicative of a reactive nonstress test.
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Correct Answer is A
Explanation
Choice A rationale
An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.
Choice B rationale
While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.
Choice C rationale
Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.
Choice D rationale
Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.
Correct Answer is D
Explanation
Choice A rationale
Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.
Choice B rationale
Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-
circumcision healing.
Choice C rationale
Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,
not a result of urine exposure.
Choice D rationale
Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .