2024 MATERNITY EVOLVE EXAN WITH RATIONALE
• A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as:
A. Normal
B. Reactive
C. Nonreactive
D. Inconclusive
Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration t
o the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording.
Test-Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results.
• A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is:
A. Contacting the physician
B. Documenting the findings
C. Continuing to monitor the client
• A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?
A. “I know how you feel.”
B. “This must be hard for you.”
C. “Now you have an angel in heaven.”
D. “You’re young. You can have other children.”
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