2
Maternity Evolve
Exam …
1. 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 Correct
D. Inconclusive
2. 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 Correct
B. Documenting the findings
C. Continuing to monitor the client
D. Reassuring the client and her partner that labor is progressing normally
3. A stillborn infant was delivered a few hours ago. After the birth, the family remains together,
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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 to the end, in association with fetal movement, during a
20minute 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 40 minute observation. An inconclusive result
is one that cannot be interpreted because of the poor quality of the fetal heart rate recording.
TestTaking 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.
Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or
longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia,
persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min.
Therefore, because the finding is abnormal, the physician must be contacted. Continuing to monitor the
client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect.
The nurse would document the data, actions taken, and the client’s response, but, of the options
provided, contacting the physician is the most appropriate.
TestTaking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the
options that are comparable or alike and indicate that the data in the question are normal findings.
Review normal assessment findings during the labor process if you had difficulty with this question.
