11. Fetal Assessment & Diagnostics(100% Verified)
normal fetal heart rate (FHR) correct answers 110-160/min
nonstress test (NST) correct answers -monitors response of FHR to fetal movement using an
ultrasound transducer
-lasts 20 min
reactive NST correct answers -FHR normal baseline (110-160 bpm)
-moderate variability
-accelerates at least 15/min for at least 15 sec
-occurs 2x during a 20-min period
nonreactive NST correct answers -does not demonstrate at least 2 qualifying accelerations in a
20-min window
-further assessment is indicated (contraction stress test, biophysical profile)
contraction stress test (CST) correct answers -monitors FHR
-uterus is stimulated to contract with small amounts of oxytocin or nipple stimulation
-indicated after a nonreactive NST
biophysical profile (BPP) correct answers observation of fetal responses to stimuli
5 components:
1. fetal breathing movements
2. fetal body movements
3. fetal tone
4. amniotic fluid volume
5. NST/FHR
BPP scoring correct answers each of the 5 components is given a score of either 2 (normal) or 0
(abnormal)
-8-10 = normal, low risk of chronic fetal asphyxia
-4-6 = abnormal, suspect chronic fetal asphyxia
-<4 = abnormal, strongly suspect chronic fetal asphyxia
amniocentesis correct answers the aspiration of amniotic fluid using a needle
A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects
data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is
appropriate?
1. Document the findings.
2. Notify the health care provider (HCP).
3. Inform the client that everything is normal and fine.
4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.
correct answers 2. Notify the health care provider (HCP).
, (FHR should be 110 to 160 beats/min)
NCLEX
The nurse in a health care clinic is instructing a client on how to perform kick counts. Which
statement made by the client indicates a need for further teaching?
1. "I should lie on my back to perform the procedure."
2. "I will use a clock or a timer and record the number of movements or kicks."
3. "I should count the fetal movements for 30 to 60 minutes 3 times a day."
4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal
movements to count the kicks." correct answers 1. "I should lie on my back to perform the
procedure."
(pt should lie on her side)
NCLEX
A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure.
How should the nurse respond?
1. "The test is a procedure that will require an informed consent to be signed."
2. "The test will take about 2 hours and will require close monitoring for 2 hours after the
procedure is completed."
3. "The test is done to see if the baby can handle the stress of labor, and medicine is given to
make the uterus contract."
4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart
activity on the recording paper and is secured over the abdomen." correct answers 4. "A round,
hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the
recording paper and is secured over the abdomen."
NCLEX
A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse
should tell the woman that which will occur?
1. She will feel some pain during the procedure.
2. She will be placed in a supine left side-lying position.
3. She will feel some pressure when the vaginal probe is moved.
4. She will need to drink 2 quarts of water to attain a full bladder. correct answers 3. She will feel
some pressure when the vaginal probe is moved.
NCLEX
A pregnant client in the prenatal clinic is scheduled for a biophysical profile. The client asks the
nurse what this test involves. The nurse should make which appropriate response?
1. "This test measures your ability to tolerate the pregnancy."
2. "This test measures amniotic fluid volume and fetal activity."
3. "This test measures your cardiac status and ability to tolerate labor."
normal fetal heart rate (FHR) correct answers 110-160/min
nonstress test (NST) correct answers -monitors response of FHR to fetal movement using an
ultrasound transducer
-lasts 20 min
reactive NST correct answers -FHR normal baseline (110-160 bpm)
-moderate variability
-accelerates at least 15/min for at least 15 sec
-occurs 2x during a 20-min period
nonreactive NST correct answers -does not demonstrate at least 2 qualifying accelerations in a
20-min window
-further assessment is indicated (contraction stress test, biophysical profile)
contraction stress test (CST) correct answers -monitors FHR
-uterus is stimulated to contract with small amounts of oxytocin or nipple stimulation
-indicated after a nonreactive NST
biophysical profile (BPP) correct answers observation of fetal responses to stimuli
5 components:
1. fetal breathing movements
2. fetal body movements
3. fetal tone
4. amniotic fluid volume
5. NST/FHR
BPP scoring correct answers each of the 5 components is given a score of either 2 (normal) or 0
(abnormal)
-8-10 = normal, low risk of chronic fetal asphyxia
-4-6 = abnormal, suspect chronic fetal asphyxia
-<4 = abnormal, strongly suspect chronic fetal asphyxia
amniocentesis correct answers the aspiration of amniotic fluid using a needle
A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects
data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is
appropriate?
1. Document the findings.
2. Notify the health care provider (HCP).
3. Inform the client that everything is normal and fine.
4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.
correct answers 2. Notify the health care provider (HCP).
, (FHR should be 110 to 160 beats/min)
NCLEX
The nurse in a health care clinic is instructing a client on how to perform kick counts. Which
statement made by the client indicates a need for further teaching?
1. "I should lie on my back to perform the procedure."
2. "I will use a clock or a timer and record the number of movements or kicks."
3. "I should count the fetal movements for 30 to 60 minutes 3 times a day."
4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal
movements to count the kicks." correct answers 1. "I should lie on my back to perform the
procedure."
(pt should lie on her side)
NCLEX
A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure.
How should the nurse respond?
1. "The test is a procedure that will require an informed consent to be signed."
2. "The test will take about 2 hours and will require close monitoring for 2 hours after the
procedure is completed."
3. "The test is done to see if the baby can handle the stress of labor, and medicine is given to
make the uterus contract."
4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart
activity on the recording paper and is secured over the abdomen." correct answers 4. "A round,
hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the
recording paper and is secured over the abdomen."
NCLEX
A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse
should tell the woman that which will occur?
1. She will feel some pain during the procedure.
2. She will be placed in a supine left side-lying position.
3. She will feel some pressure when the vaginal probe is moved.
4. She will need to drink 2 quarts of water to attain a full bladder. correct answers 3. She will feel
some pressure when the vaginal probe is moved.
NCLEX
A pregnant client in the prenatal clinic is scheduled for a biophysical profile. The client asks the
nurse what this test involves. The nurse should make which appropriate response?
1. "This test measures your ability to tolerate the pregnancy."
2. "This test measures amniotic fluid volume and fetal activity."
3. "This test measures your cardiac status and ability to tolerate labor."
