A patient at 36 weeks gestation is undergoing a nonstress test (NST). The nurse observes the fetal heart rate baseline at 135 bpm and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for 20-25 seconds each. How will the nurse record these findings?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) NST reactive, reassuring. This is because the fetal heart rate baseline is within normal limits (110-160 bpm) and there are accelerations of at least 15 bpm lasting for at least 15 seconds, which indicate a reactive NST. These findings suggest that the fetus is well-oxygenated and not experiencing distress during the monitoring period. Option A) NST positive, nonreassuring is incorrect because a positive NST would indicate abnormal findings such as late decelerations, decreased variability, or bradycardia, which are not present in this case. Option B) NST negative, reassuring is incorrect because a negative NST typically refers to a test that does not show the expected number of accelerations, which is not the case here as the test is reactive. Option D) NST nonreactive, nonreassuring is incorrect as the test described in the question is actually reactive and reassuring. Educationally, understanding the interpretation of fetal heart rate monitoring is crucial for assessing fetal well-being during labor. Nurses and healthcare providers need to accurately interpret NST results to make timely and appropriate clinical decisions regarding the management of labor and delivery. Regular review and practice of interpreting fetal heart rate monitoring findings are essential skills for healthcare professionals involved in obstetric care.

Correct Answer: B

Rationale: The correct answer is B) 20 weeks pregnant. Fundal height measurement is a crucial component of monitoring fetal growth and development during pregnancy. At 20 weeks, the fundal height typically corresponds to the level of the umbilicus. This measurement helps assess fetal growth and ensures appropriate development in utero. In this case, the fundal height corresponds to 20 weeks, indicating normal growth for this stage of pregnancy. Option A) 12 weeks is incorrect because at 12 weeks, the fundal height would be much lower than what is indicated in the image. The fundus is typically palpable just above the pubic symphysis at 12 weeks. Option C) 28 weeks is incorrect because at 28 weeks, the fundal height would be higher than the level shown in the image. By 28 weeks, the fundus is usually at the level of the xiphoid process. Option D) 36 weeks is incorrect because at 36 weeks, the fundal height would be significantly higher, typically reaching its highest point just below the xiphoid process. Understanding fundal height measurement is essential for healthcare providers to monitor fetal growth accurately and detect any deviations that may indicate potential issues. It allows for appropriate interventions to be implemented in a timely manner to ensure the well-being of both the mother and the baby.

Correct Answer: D

Rationale: The correct answer is D) The test should take one hour to complete. Rationale: The preprocedure teaching for a glucose challenge test (GCT) is crucial for the patient to understand what to expect during the test. The correct answer, D, is essential because it informs the pregnant woman about the expected duration of the test, which is approximately one hour. This information helps the patient plan accordingly and manage their time efficiently on the day of the test. Option A, fasting for 12 hours before the test, is incorrect because a GCT does not require fasting. In fact, fasting can affect the results of the test, leading to inaccurate findings. Option B, bringing a urine specimen to the laboratory on the day of the test, is also incorrect as a GCT does not involve testing urine. The test primarily involves blood samples to measure glucose levels. Option C, being prepared to have 4 blood specimens taken on the day of the test, is incorrect as well. Typically, a GCT requires only one or two blood samples to be drawn at specific time points during the test, not four. Educational context: Understanding the instructions for a GCT is vital for pregnant women as it helps in ensuring accurate test results and a smooth testing experience. By providing clear and accurate preprocedure teaching, healthcare providers can help alleviate anxiety, improve patient compliance, and enhance the overall quality of care provided to pregnant women undergoing this test.

Correct Answer: B

Rationale: The correct answer is B) Nodular breast tissue is normal during pregnancy. This response is based on the understanding that hormonal changes during pregnancy can lead to breast changes, including nodularity and lumps, which are usually benign and part of the normal physiological process of pregnancy. Educating the client about these normal changes can help alleviate her fears and concerns. Option A is incorrect because breast cancer is not typically triggered by pregnancy itself, although changes in the breasts during pregnancy may lead to concerns about cancer. Option C is incorrect as there is no evidence in the scenario provided to suggest that the woman is exhibiting signs of a psychotic break. Her fear and anxiety are understandable given her gestational stage and lack of knowledge about normal breast changes. Option D is incorrect as anxiety attacks are not specifically associated with the second trimester of pregnancy. While anxiety and stress can occur at any point during pregnancy, the woman's concerns about breast changes should be addressed with accurate information rather than generalized statements about anxiety. In an educational context, it is crucial for healthcare providers to have a thorough understanding of the normal physiological changes that occur during pregnancy to provide appropriate support and information to pregnant individuals. Addressing fears and concerns with accurate knowledge and empathy is essential in promoting the well-being of both the mother and the baby.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Fundal height. During pregnancy, fundal height measurement is a crucial parameter to monitor fetal growth and development. In this case, the client's complaint of dyspnea when lying flat could be indicative of supine hypotensive syndrome, a condition where the weight of the uterus compresses the inferior vena cava when the mother is lying on her back, leading to decreased venous return and subsequent hypotension. Option A) Maternal hypertension is incorrect as dyspnea when lying flat is not a typical symptom of hypertension. Option C) Hydramnios refers to excessive amniotic fluid, which may present with other symptoms such as abdominal discomfort or rapid uterine growth, but not necessarily dyspnea when lying flat. Option D) Congestive heart failure is less likely in a 36-week pregnant client without a history of cardiac issues. Educationally, understanding the significance of fundal height measurement in monitoring fetal well-being and recognizing signs and symptoms of complications during pregnancy are essential skills for healthcare providers involved in maternity care. It is vital to differentiate between normal discomforts of pregnancy and potential warning signs that require prompt assessment and intervention to ensure the well-being of both the mother and baby.