Practice Quiz

NCLEX-PN

Category - Health Promotion

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The nurse assesses the well-being of a 24-week fetus. Which of the following observations should alert the nurse to refer the client for further evaluation?
  1. More than 5 fetal movements per hour using the Sandosvsky method
  2. More than 3 accelerations of fetal heart rate lasting for 15 seconds occurring after fetal movements in 20 minutes
  3. Increase of 15 beats per minute, remaining elevated for 15 seconds after each fetal movement
  4. No increase in fetal heart beat after fetal movements
Explanation
Answer: D - Absence of increase in fetal heart rate after fetal movements should be referred for further evaluation. The other options demonstrate good fetal well-being.
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