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 Corre
...
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
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 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 40-
minute 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.
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
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.
Test-Taking 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.
3. 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.” Correct
C. “Now you have an angel in heaven.”
D. “You’re young. You can have other children.”
Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and
emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging
communication. The other options are nontherapeutic and may devalue the family members' feeling
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