Chapter 09: Assessing the Fetus NCLEX

9. Which factors should be considered a contraindication for transcervical chorionic villus sampling? a. Rh-negative mother b. Gestation less than 15 weeks c. Maternal age younger than 35 years d. Positive for group B Streptococcus

ANS: D Maternal infection is a risk with this procedure, and it is contraindicated if the patient has an active infection in the cervix, vagina, or pelvic area. This procedure is done between 10 and 12 weeks. This procedure is usually done for women older than 35; however, if the woman is at high risk for fetal anomalies, her age is not a contraindication. The procedure can still be performed; however, Rh sensitization may occur if the mother is Rh-negative. Rho(D) immune globulin can be administered following the procedure.

13. What is the purpose of initiating contractions in a contraction stress test (CST)? a. Increase placental blood flow. b. Identify fetal acceleration patterns. c. Determine the degree of fetal activity. d. Apply a stressful stimulus to the fetus

ANS: D The CST involves recording the response of the fetal heart rate to stress induced by uterine contractions. The CST records the fetal response to stress. It does not increase placental blood flow. The NST looks at fetal heart accelerations with fetal movements. The NST and biophysical profiles look at fetal movements

11. What does optimal nursing care after an amniocentesis include? a. Pushing fluids by mouth b. Monitoring uterine activity c. Placing the patient in a supine position for 2 hours d. Applying a pressure dressing to the puncture site

ANS: B A risk with amniocentesis is the onset of spontaneous contractions. Hydration is important; however, the woman has not been NPO, so this should not be a problem. The supine position may decrease uterine blood flow; the side-lying position is preferred. Pressure dressings are not necessary.

22. The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks' gestation. The nurse determines that the patient understands the teaching when she states that will be collected for the initial screening process? a. Urine b. Blood c. Saliva d. Amniotic fluid

ANS: B Initial screening is completed with blood. AFP can be detected in amniotic fluid; however, that procedure is more costly and invasive. Procedures progress from least invasive to most invasive

5. The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition? a. Hemophilia b. Sickle cell anemia c. A neural tube defect d. Abnormal lecithin-to-sphingomyelin ratio

ANS: C An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter the maternal serum. Hemophilia is a genetic defect and is best detected with chromosomal studies, such as chorionic villus sampling or amniocentesis. Sickle cell anemia is a genetic defect and is best detected with chromosomal studies such as chorionic villus sampling or amniocentesis. L/S ratios are determined with an amniocentesis and are usually performed in the third trimester.

6. When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks

ANS: C CVS is normally performed between 10 and 13 weeks gestation. The fetal villus tissue can be analyzed directly for chromosomal, metabolic, or DNA abnormalities. It is too early to perform CVS at 4 or 8 weeks of pregnancy. The test can no longer be performed a 14 weeks gestation. Results are available within 24 to 48 hours.

1. Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)? (Select all that apply.) a. Down syndrome b. Molar pregnancy c. Twin gestation d. Incorrect gestational age assessment of a normal fetus—estimation is earlier in the pregnancy e. Threatened abortion

ANS: C, D, E Elevated APF levels are seen in multiple gestations, underestimation of fetal age, and threatened abortion. Decreased levels are seen in Down syndrome and a molar pregnancy

5. The nurse is preparing a patient for a nonstress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.) a. Ensure that the patient has a full bladder. b. Plan approximately 15 minutes for the test. c. Have the patient sit in a recliner with the head elevated 45 degrees. d. Apply electronic monitoring equipment to the patient's abdomen. e. Instruct the patient to press an event marker every time she feels fetal movement

ANS: C, D, E The patient may be seated in a reclining chair or have her head elevated at least 45 degrees. The nurse applies external electronic monitoring equipment to the patient's abdomen to detect the fetal heart rate and any contractions. The woman may be given an event marker to press each time she senses movement. Before the NST, the patient should void and her baseline vital signs should be taken. The NST takes about 40 minutes, allowing for most fetal sleep-wake cycles, although the fetus may show a reassuring pattern more quickly or need more time to awaken and become active. Fifteen minutes would not allow enough time to complete the test.

7. Which aspect of fetal diagnostic testing is most important to expectant parents? a. Safety of the fetus b. Duration of the test c. Cost of the procedure d. Physical discomfort caused by the procedure

ANS: A Although all of these are considerations, parents are usually most concerned about the safety of the fetus. Parents are concerned about the duration of the test; however, it is not the greatest concern. The cost of the procedure is important to parents, especially those without third-party payers; but again, this is not the greatest concern. With adequate preparation for the procedure by the nurse physical discomfort can be allayed

21. A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound? a. Immediately b. In 2 weeks c. In 4 weeks d. In 6 weeks

ANS: A An embryo can be seen about 5 to 6 weeks after the last menstrual period. At this time the crown-rump length (CRL) of the embryo is the most reliable measure of gestational age. Fetal viability is confirmed by observation of fetal heartbeat, which is visible when the CRL of the embryo is 5 mm.

3. The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history? a. Maternal diabetes b. Weight gain of 25 lb c. Maternal age older than 30 years d. Previous infant weighing more than 3000 g at birth

ANS: A Diabetes is a risk factor in pregnancy because of possible impairment of placental perfusion. Excessive weight gain is an indication for testing. Normal weight gain is 25 to 35 lb. A maternal age older than 35 years is an indication for testing. Having had another infant weighing more than 4000 g is an indication for testing.

4. What point in the pregnancy is the most accurate time to determine gestational age through ultrasound? a. First trimester b. Second trimester c. Third trimester d. No difference in accuracy among the trimesters

ANS: A Gestational age determination by ultrasonography is increasingly less accurate after the first trimester. Gestational age determination is best done in the first trimester. There is a difference in trimesters when doing a gestational age ultrasonography.

2. Transvaginal ultrasonography is often performed during the first trimester. A 6-week-gestation patient expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be necessary to determine which of the following? (Select all that apply.) a. Multifetal gestation b. Bicornuate uterus c. Presence and location of pregnancy d. Amniotic fluid volume e. Presence of ovarian cysts

ANS: A, B, C, E A bicornuate uterus, multifetal gestation, presence of ovarian cysts, and presence and location of pregnancy can be determined by transvaginal ultrasound in the first trimester of pregnancy. This procedure is also used for estimating gestational age, confirming fetal viability, identifying fetal abnormalities or chromosomal defects, and identifying the maternal abnormalities mentioned, as well as fibroids. Amniotic fluid volume is assessed during the second and third trimesters. Conventional ultrasound would be used.

1. A pregnant patient's biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse's most appropriate response? a. "The test results are within normal limits." b. "Immediate birth by cesarean birth is being considered." c. "Further testing will be performed to determine the meaning of this score." d. "An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth."

ANS: A The normal biophysical score ranges from 8 to 10 points if the amniotic fluid volume is adequate. A normal score allows conservative treatment of high-risk patients. Birth can be delayed if fetal well-being is an issue. Scores less than 4 would be investigated, and birth could be initiated sooner than planned. This score is within normal range, and no further testing is required at this time. The results of the biophysical profile are usually available immediately after the procedure is performed

4. The nurse is instructing a patient on how to perform kick counts. Which information should the nurse include in the teaching session? (Select all that apply.) a. Use a clock or timer when performing kick counts. b. Your bladder should be full before performing kick counts. c. Notify your health care provider if you have not felt movement in 24 hours. d. Protocols can provide a structured timetable for concentrating on fetal movements. e. You should lie on your side, place your hands on the largest part of the abdomen, and concentrate on the number of movements felt

ANS: A, D, E The nurse should instruct the patient to lie on her side, place her hands on the largest part of her abdomen, and concentrate on fetal movements. She should use a clock or timer and record the number of movements felt during that time. Protocols are not essential; however, they may give the patient a more structured timetable for when to concentrate on fetal movements. The bladder does not need to be full for kick counts; it is better to have the patient empty her bladder before beginning the assessment of fetal movements. Further evaluation is recommended if the patient feels no movements in 12 hours; 24 hours is too long before notifying the health care provider.

16. The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result? a. Repeat the test in 1 week so that results can be trended based on this baseline result. b. Contact the health care provider to discuss birth options for the patient. c. Send the patient out for a meal and repeat the test to confirm that the results are valid. d. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.

ANS: B A positive CST test is an abnormal finding, and the provider should be notified so that birth options can be initiated. A positive CST indicates possible fetal compromise. Intervention should not be delayed by 1 week and results do not have to be trended. Because this is an abnormal result, there is no need to repeat the test. Sending the patient out for a meal will delay treatment options and may interfere with possible birth interventions if anesthesia is needed. Fetal kick count assessment is not needed at this time and will further delay treatment interventions for this abnormal result, which indicates fetal compromise

17. A pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient's plan of care? a. No further testing is indicated at this time because results are normal. b. Refer to the physician for additional testing. c. Validate the results with the lab facility. d. Repeat the test in 2 weeks and have the patient return for her regularly scheduled prenatal visit.

ANS: B Additional genetic testing is indicated to provide the patient with treatment options. A positive result on a triple-screen test is considered to be an abnormal finding so the patient should be referred to the physician for additional genetic testing. Validation of the test with a lab facility is not necessary because the patient provided you with a copy of the test results. There is no need to repeat the clinical test because the findings have already been determined.

19. For which patient would an L/S ratio of 2:1 potentially be considered abnormal? a. A 38-year-old gravida 2, para 1, who is 38 weeks' gestation b. A 24-year-old gravida 1, para 0, who has diabetes c. A 44-year-old gravida 6, para 5, who is at term d. An 18-year-old gravida 1, para 0, who is in early labor at term

ANS: B Even though an L/S ratio of 2:1 is typically considered to be a normal finding to validate fetal lung maturity prior to 38 weeks' gestation, the result may not be accurate in determining fetal lung maturity if a patient is diabetic

2. Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus? a. Biophysical profile b. Multiple-marker screening c. Lecithin-to-sphingomyelin ratio d. Blood type and crossmatch of maternal and fetal serum

ANS: B Maternal serum can be analyzed for abnormal levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), inhibin A, and estriol. The multiple-marker screening may predict chromosomal defects in the fetus. The biophysical profile is used to evaluate fetal status during the antepartum period. Five variables are used; however, none are concerned with chromosomal problems. The lecithin-to-sphingomyelin ratio is used to determine fetal lung maturity. The blood type and crossmatch will not predict chromosomal defects in the fetus.

20. Which complication could occur as a result of percutaneous umbilical blood sampling (PUBS)? a. Postdates pregnancy b. Fetal bradycardia c. Placenta previa d. Uterine rupture

ANS: B PUBS is an invasive test whereby a needle is inserted into the umbilical cord to obtain blood as the basis for diagnostic testing with the guidance of ultrasound technology. The most common complication is fetal bradycardia, which is temporary. PUBS has no effect on extending the gestation of pregnancy, the development of placenta previa, or uterine rupture.

14. A biophysical profile is performed on a pregnant patient. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. Which answer would be the correct interpretation of this test result? a. A score of 10 would indicate that the results are equivocal. b. A score of 8 would indicate normal results. c. A score of 6 would indicate that birth should be considered as a possible treatment option. d. A score of 9 would indicate reassurance.

ANS: B The biophysical profile is used to assess fetal well-being. Five categories of assessment are used in this combination test: fetal monitoring NST, evaluation of FBMs, gross movements, fetal tone, and calculation of the amniotic fluid index (AFI). A maximum of 2 points is used if criteria are met successfully in each category; thus a score in the range of 8 to 10 indicates a normal or reassuring finding. A score of 6 provides equivocal results and further testing or observation is necessary. A score of 4 or less requires immediate intervention, and birth may be warranted. The provided assessments indicate a score of 8 as the only area that has not met the stated criteria in the NST.

8. The nurse's role in diagnostic testing is to provide which of the following? a. Advice to the couple b. Information about the tests c. Reassurance about fetal safety d. Assistance with decision making

ANS: B The nurse should provide the couple with all necessary information regarding a procedure so that the couple can make an informed decision. The nurse's role is to inform, not to advice. Ensuring fetal safety is not possible with all the diagnostic tests. To offer this is to give false reassurance to the parents. The nurse can inform the couple about potential problems so they can make an informed decision. Decision making should always lie with the couple involved. The nurse should provide information so that the couple can make an informed decision.

3. A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator (VAS) test. Which should the nurse include in the response? (Select all that apply.) a. The test is invasive. b. The test uses sound to elicit fetal movements. c. The test may confirm nonreactive nonstress test results. d. The test can only be performed if contractions are present. e. Vibroacoustic stimulation can be repeated at 1-minute intervals up to three times.

ANS: B, C, E Also referred to as VAS or acoustic stimulation, the vibroacoustic stimulator (similar to an electronic larynx) is applied to the maternal abdomen over the area of the fetal head. Vibration and sound are emitted for up to 3 seconds and may be repeated. A fetus near term responds by increasing the number of gross body movements, which can be easily seen and felt. The procedure can confirm reassuring NST findings and shorten the length of time necessary to obtain NST data. The test is noninvasive and contractions do not need to be present to perform the test.

18. A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered? a. Magnesium sulfate b. Prostaglandin suppository c. RhoGAM if the patient is Rh-negative d. Betamethasone

ANS: C CVS can increase the likelihood of Rh sensitization if a woman is Rh-negative. There is no indication for magnesium sulfate because it is used to stop preterm labor. There is no indication for administration of a prostaglandin suppository. Betamethasone is given to pregnant women in preterm labor to improve fetal lung maturity.

12. What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period? a. Positive b. Negative c. Reactive d. Nonreactive

ANS: C The nonstress test (NST) is reactive (normal) when there are two or more fetal heart rate accelerations of at least 15 BPM (each with a duration of at least 15 seconds) in a 20-minute period. A positive result is not used with an NST. The contraction stress test (CST) uses positive as a result term. A negative result is not used with an NST. The CST uses negative as a result term. A nonreactive result means that the heart rate did not accelerate during fetal movement.

15. In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care? a. Have the patient void prior to being placed on the fetal monitor because a full bladder will interfere with results. b. Maintain NPO status prior to testing. c. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate. d. Have an infusion pump prepared with oxytocin per protocol for evaluation

ANS: C The nurse must adjust the tocotransducer to find the best location to pick up and record the fetal heart rate. Positioning the patient for comfort during testing is a prime concern. Although a full bladder may affect patient comfort, it will not interfere with testing results. NPO status is not required for an NST. Instead, a pregnant patient should maintain her normal nutritional intake to provide energy to herself and the fetus. An infusion pump with oxytocin is required for a contraction stress test (CST).

23. A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings? a. NST positive, nonreassuring b. NST negative, reassuring c. NST reactive, reassuring d. NST nonreactive, nonreassuring

ANS: C The presence of at least three accelerations of at least 15 beats, over at least 15 seconds, over a duration of at least 20 minutes, is considered reactive and reassuring. Nonreactive testing reveals no or fewer accelerations over the same or longer period. The NST test is not recorded as positive or negative

10. What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension? a. Determine if a metabolic disorder exists. b. Identify the sex of the fetus. c. Identify abnormal fetal cells. d. Determine fetal lung maturity

ANS: D During the third trimester, amniocentesis is most often performed to determine fetal lung maturity. In cases of pregnancy-induced hypertension, preterm birth may be necessary because of changes in placental perfusion. The test is done in the early portion of the pregnancy if a metabolic disorder is genetic. Amniocentesis is done early in the pregnancy to do genetic studies and determine the sex. Identification of abnormal cells is done during the early portion of the pregnancy.