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, option C) NST reactive, reassuring is the correct answer. When interpreting a nonstress test (NST), it is essential to understand the parameters that indicate a reassuring or non-reassuring result. A reactive NST is characterized by the presence of at least two accelerations of the fetal heart rate, each lasting 15 seconds and reaching a peak of at least 15 bpm above baseline within a 20-minute window. In this case, the fetal heart rate baseline at 135 bpm and the nonepisodic patterns reaching 160 bpm for 20-25 seconds each indicate variability and accelerations, meeting the criteria for a reactive NST. Option A) NST positive, nonreassuring would be incorrect because a positive result typically indicates abnormal findings, such as decelerations, which are not present in this case. Option B) NST negative, reassuring is incorrect as a negative result usually signifies non-reactivity, which is not the case here. Option D) NST nonreactive, nonreassuring is also incorrect based on the presence of accelerations and variability in the fetal heart rate, which are indicative of a reactive and reassuring test. Educationally, understanding how to interpret fetal monitoring tests like the NST is crucial for healthcare providers involved in maternal and fetal care. By correctly interpreting these tests, healthcare professionals can make timely and appropriate decisions to ensure the well-being of both the mother and the baby during labor and delivery. It is important for nurses and other healthcare providers to be familiar with the criteria for interpreting NST results to provide optimal care for pregnant patients.

Correct Answer: B

Rationale: In this question, the correct answer is B) 20 weeks pregnant. The fundal height measurement is a crucial assessment during pregnancy to estimate fetal growth and gestational age. At 20 weeks, the fundal height is expected to be at the level of the umbilicus. This corresponds to the location indicated in the picture. Option A) 12 weeks is incorrect because at 12 weeks, the fundal height would be well below the umbilicus. Option C) 28 weeks is incorrect as the fundal height at this stage would be above the umbilicus. Option D) 36 weeks is also incorrect as by this time, the fundal height would be at its highest point, well above the umbilicus. Educationally, understanding fundal height measurement is essential for healthcare professionals involved in monitoring pregnancy. It helps assess fetal growth, detect potential issues, and guide further evaluations or interventions. Proper measurement technique and interpretation are crucial skills for midwives, nurses, and other healthcare providers caring for pregnant individuals.

Correct Answer: D

Rationale: The correct answer is D) The test should take one hour to complete. Rationale: The glucose challenge test (GCT) is a screening test for gestational diabetes. It involves drinking a glucose solution and then having blood drawn to measure glucose levels. The test typically takes one hour to complete because it involves monitoring blood glucose levels at specific intervals to assess how the body processes the glucose. Option A) Fast for 12 hours before the test is incorrect because fasting is not required for a GCT. In fact, it is important for the pregnant woman to eat normally before the test to get an accurate result. Option B) Bring a urine specimen to the laboratory on the day of the test is incorrect because the GCT requires blood samples, not urine samples, for glucose monitoring. Option C) Be prepared to have 4 blood specimens taken on the day of the test is incorrect because typically only one or two blood samples are needed for the GCT, not four. Educational Context: It is crucial for healthcare providers to educate pregnant women about the procedures they will undergo during pregnancy to ensure they understand what to expect and can participate actively in their care. Providing accurate information about the GCT, including the duration of the test and what to expect during the procedure, can help alleviate anxiety and promote cooperation from the pregnant woman.

Correct Answer: B

Rationale: In this scenario, the correct response is option B: Nodular breast tissue is normal during pregnancy. This response is correct because during pregnancy, hormonal changes lead to an increase in breast size and nodularity due to the growth of mammary glands and ducts in preparation for lactation. It is crucial for the nurse to provide accurate information and reassurance to the client to alleviate her fears. Option A is incorrect because breast cancer is not typically triggered by pregnancy, although pregnancy can impact the management of existing breast cancer. Option C is incorrect as there is no indication in the scenario that the woman is experiencing a psychotic break; rather, she is expressing fear and concern. Option D is incorrect as anxiety attacks are not specifically linked to the second trimester; anxiety can occur at any point during pregnancy. Educationally, this scenario highlights the importance of understanding the normal physiological changes that occur during pregnancy and being able to provide accurate information and support to pregnant individuals experiencing fears or concerns about their health. It underscores the role of healthcare providers, especially nurses, in providing education and reassurance to promote maternal well-being during pregnancy.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Fundal height. Dyspnea when lying flat in a 36-week gestation gravid client is indicative of supine hypotensive syndrome, also known as aortocaval compression syndrome. This occurs when the gravid uterus compresses the inferior vena cava and abdominal aorta when the client lies flat on her back. Fundal height measurement helps to assess the size of the uterus and the position of the fetus, which is crucial in determining the risk of aortocaval compression syndrome. Option A) Maternal hypertension is incorrect because dyspnea when lying flat is not typically associated with hypertension. Option C) Hydramnios (excessive amniotic fluid) is incorrect as it is not directly related to the client's symptom of dyspnea when lying flat. Option D) Congestive heart failure is incorrect in this context as the symptom is more likely related to the mechanical compression of the vena cava by the gravid uterus rather than heart failure. Educationally, understanding the significance of fundal height measurement in assessing gestational age, fetal growth, and potential complications like aortocaval compression syndrome is essential for healthcare providers involved in monitoring pregnant clients during labor. Recognizing and addressing issues like supine hypotensive syndrome promptly can help prevent complications and ensure the well-being of both the mother and the baby.