Chapter 26: Assessment of High Risk Pregnancy

IUGR is associated with which pregnancy-related risk factors? (Select all that apply.) a.Poor nutrition b.Maternal collagen disease c.Gestational hypertension d.Premature rupture of membranes e.Smoking

ANS: A, B, C, E Poor nutrition, maternal collagen disease, gestational hypertension, and smoking are risk factors associated with the occurrence of IUGR. Premature rupture of membranes is associated with preterm labor, not IUGR.

Biophysical risks include factors that originate with either the mother or the fetus and affect the functioning of either one or both. The nurse who provides prenatal care should have an understanding of these risk factors. Match the specific pregnancy problem with the related risk factor. a.Polyhydramnios b.IUGR (maternal cause) c.Oligohydramnios d.Chromosomal abnormalities e.IUGR (fetoplacental cause) 1. Premature rupture of membranes 2. Advanced maternal age 3. Fetal congenital anomalies 4. Abnormal placenta development 5. Smoking, alcohol, and illicit drug use

1. ANS: C DIF: Cognitive Level: Understand REF: p. 635 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. ANS: D DIF: Cognitive Level: Understand REF: p. 635 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 3. ANS: A DIF: Cognitive Level: Understand REF: p. 635 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. ANS: E DIF: Cognitive Level: Understand REF: p. 635 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. ANS: B DIF: Cognitive Level: Understand REF: p. 635

The indirect Coombs' test is a screening tool for Rh incompatibility. If the titer is greater than ______, amniocentesis may be a necessary next step. a.1:2 b.1:4 c.1:8 d.1:12

ANS: C If the maternal titer for Rh antibodies is greater 1:8, then an amniocentesis is indicated to determine the level of bilirubin in the amniotic fluid. This testing will determine the severity of fetal hemolytic anemia.

A woman is undergoing a nipple-stimulated CST. She is having contractions that occur every 3 minutes. The fetal heart rate (FHR) has a baseline heart rate of approximately 120 beats per minute without any decelerations. What is the correct interpretation of this test? a.Negative b.Positive c.Satisfactory d.Unsatisfactory

ANS: A Adequate uterine activity necessary for a CST consists of three contractions in a 10-minute time frame. If no decelerations are observed in the FHR pattern with the contractions, then the findings are considered to be negative. A positive CST indicates the presence of repetitive late FHR decelerations. The terms satisfactory or unsatisfactory are not applicable.

Which information is the highest priority for the nurse to comprehend regarding the BPP? a.BPP is an accurate indicator of impending fetal well-being. b.BPP is a compilation of health risk factors of the mother during the later stages of pregnancy. c.BPP consists of a Doppler blood flow analysis and an amniotic fluid index (AFI). d.BPP involves an invasive form of an ultrasonic examination.

ANS: A An abnormal BPP score is one indication that labor should be induced. The BPP evaluates the health of the fetus, requires many different measures, and is a noninvasive procedure.

A client asks her nurse, "My doctor told me that he is concerned with the grade of my placenta because I am overdue. What does that mean?" What is the nurse's best response? a."Your placenta changes as your pregnancy progresses, and it is given a score that indicates how well it is functioning." b."Your placenta isn't working properly, and your baby is in danger." c."We need to perform an amniocentesis to detect if you have any placental damage." d."Don't worry about it. Everything is fine."

ANS: A An explanation of what is meant by the "grade of my placenta" is the most appropriate response. If the client desires further information, the nurse can explain that calcium deposits are significant in postterm pregnancies, and ultrasonography can also be used to determine placental aging. Although stating that the client's placenta is not working properly and that the baby is in danger may be a valid response, it does not reflect therapeutic communication techniques and is likely to alarm the client. An ultrasound, not amniocentesis, is the method of assessment used to determine placental maturation. Telling the client not to worry is not appropriate and discredits her concerns.

A 39-year-old primigravida woman believes that she is approximately 8 weeks pregnant, although she has had irregular menstrual periods all her life. She has a history of smoking approximately one pack of cigarettes a day; however, she tells the nurse that she is trying to cut down. Her laboratory data are within normal limits. What diagnostic technique would be useful at this time? a.Ultrasound examination b.Maternal serum alpha-fetoprotein (MSAFP) screening c.Amniocentesis d.Nonstress test (NST)

ANS: A An ultrasound examination could be performed to confirm the pregnancy and to determine the gestational age of the fetus. An MSAFP screening is performed at 16 to 18 weeks of gestation; therefore, it is too early in the woman's pregnancy to perform this diagnostic test. An amniocentesis is performed if the MSAFP levels are abnormal or if fetal or maternal anomalies are detected. An NST is performed to assess fetal well-being in the third trimester.

Of these psychosocial factors, which has the least negative effect on the health of the mother and/or fetus? a.Moderate coffee consumption b.Moderate alcohol consumption c.Cigarette smoke d.Emotional distress

ANS: A Birth defects in humans have not been related to caffeine consumption. Pregnant women who consume more than 300 mg of caffeine daily may be at increased risk for miscarriage or IUGR. Although the exact effects of alcohol in pregnancy have not been quantified, it exerts adverse effects on the fetus including fetal alcohol syndrome, fetal alcohol effects, learning disabilities, and hyperactivity. A strong, consistent, causal relation has been established between maternal smoking and reduced birth weight. Childbearing triggers profound and complex physiologic and psychologic changes on the mother. Evidence suggests a relationship between emotional distress and birth complications.

The nurse sees a woman for the first time when she is 30 weeks pregnant. The client has smoked throughout the pregnancy, and fundal height measurements now are suggestive of intrauterine growth restriction (IUGR) in the fetus. In addition to ultrasound to measure fetal size, what is another tool useful in confirming the diagnosis? a.Doppler blood flow analysis b.Contraction stress test (CST) c.Amniocentesis d.Daily fetal movement counts

ANS: A Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high-risk pregnancies because of IUGR, diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.

Which analysis of maternal serum may predict chromosomal abnormalities in the fetus? a.Multiple-marker screening b.L/S ratio c.BPP d.Blood type and crossmatch of maternal and fetal serum

ANS: A Maternal serum can be analyzed for abnormal levels of alpha-fetoprotein, human chorionic gonadotropin, and estriol. The multiple-marker screening may predict chromosomal defects in the fetus. The L/S ratio is used to determine fetal lung maturity. A BPP is used for evaluating fetal status during the antepartum period. Five variables are used, but none is concerned with chromosomal problems. The blood type and crossmatch would not predict chromosomal defects in the fetus.

Which information is an important consideration when comparing the CST with the NST? a.The NST has no known contraindications. b.The CST has fewer false-positive results when compared with the NST. c.The CST is more sensitive in detecting fetal compromise, as opposed to the NST. d.The CST is slightly more expensive than the NST.

ANS: A The CST has several contraindications. The NST has a high rate of false-positive results and is less sensitive than the CST but relatively inexpensive.

A pregnant woman's BPP score is 8. She asks the nurse to explain the results. How should the nurse respond at this time? a."The test results are within normal limits." b."Immediate delivery 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 delivery."

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 clients. Delivery can be delayed if fetal well-being is indicated. Scores less than 4 should be investigated, and delivery could be initiated sooner than planned. The results of the BPP are usually available immediately after the procedure is performed. Since this score is within normal range, no further testing is required at this time.

Which assessments are included in the fetal BPP? (Select all that apply.) a.Fetal movement b.Fetal tone c.Fetal heart rate d.AFI e.Placental grade

ANS: A, B, C, D Fetal movement, tone, heart rate, and AFI are all assessed in a BPP. The placental grade is determined by ultrasound and is not included in the criteria of assessment factors for a BPP.

Transvaginal ultrasonography is often performed during the first trimester. While preparing a 6-week gestational client for this procedure, she expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be indicated for which situations? (Select all that apply.) a.Multifetal gestation b.Obesity c.Fetal abnormalities d.Amniotic fluid volume e. Ectopic pregnancy

ANS: A, B, C, E Transvaginal ultrasound is useful in women who are obese whose thick abdominal layers cannot be penetrated with traditional abdominal ultrasound. This procedure is also used to identify multifetal gestation, ectopic pregnancy, estimating gestational age, confirming fetal viability, and identifying fetal abnormalities. Amniotic fluid volume is assessed during the second and third trimester; conventional ultrasound would be used.

Cell-free deoxyribonucleic acid (DNA) screening is a new method of noninvasive prenatal testing (NIPT) that has recently become available in the clinical setting. This technology can provide a definitive diagnosis of which findings? (Select all that apply.) a.Fetal Rh status b.Fetal gender c.Maternally transmitted gene disorder d.Paternally transmitted gene disorder e.Trisomy 21

ANS: A, B, D, E The NIPT cannot actually distinguish fetal from maternal DNA. It can determine fetal Rh status, gender, trisomies 13, 18, and 21, as well as paternally transmitted gene disorders. The test can be performed any time after 10 weeks of gestation and is recommended for women who have previously given birth to a child with chromosomal abnormalities.

An MSAFP screening indicates an elevated level of alpha-fetoprotein. The test is repeated, and again the level is reported as higher than normal. What is the next step in the assessment sequence to determine the well-being of the fetus? a.PUBS b.Ultrasound for fetal anomalies c.BPP for fetal well-being d.Amniocentesis for genetic anomalies

ANS: B If MSAFP findings are abnormal, then follow-up procedures include genetic counseling for families with a history of NTD, repeated MSAFP screenings, an ultrasound examination, and possibly amniocentesis. Indications for the use of PUBS include prenatal diagnosis of inherited blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of the acid-base status of fetuses with IUGR, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. A BPP is a method of assessing fetal well-being in the third trimester. Before an amniocentesis, the client would have an ultrasound for direct visualization of the fetus.

The nurse is planning the care for a laboring client with diabetes mellitus. This client is at greater risk for which clinical finding? a.Oligohydramnios b.Polyhydramnios c.Postterm pregnancy d.Chromosomal abnormalities

ANS: B Polyhydramnios or amniotic fluid in excess of 2000 ml is 10 times more likely to occur in the client with diabetes mellitus rather than in nondiabetic pregnancies. This complication places the mother at risk for premature rupture of membranes, premature labor, and postpartum hemorrhage. Prolonged rupture of membranes, IUGR, intrauterine fetal death, and renal agenesis (Potter syndrome) place the client at risk for developing oligohydramnios. Anencephaly, placental insufficiency, and perinatal hypoxia contribute to the risk for postterm pregnancy. Maternal age older than 35 years and balanced translocation (maternal and paternal) are risk factors for chromosomal abnormalities.

A 41-week pregnant multigravida arrives at the labor and delivery unit after a NST indicated that her fetus could be experiencing some difficulties in utero. Which diagnostic tool yields more detailed information about the condition of the fetus? a.Ultrasound for fetal anomalies b.Biophysical profile (BPP) c.MSAFP screening d.Percutaneous umbilical blood sampling (PUBS)

ANS: B Real-time ultrasound permits a detailed assessment of the physical and physiologic characteristics of the developing fetus and a cataloging of normal and abnormal biophysical responses to stimuli. The BPP is a noninvasive, dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease. An ultrasound for fetal anomalies would most likely have occurred earlier in the pregnancy. It is too late in the pregnancy to perform an MSAFP. Furthermore, it does not provide information related to fetal well-being. Indications for PUBS include prenatal diagnosis or inherited blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of the acid-base status of the fetus with IUGR, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus.

Which clinical finding is a major use of ultrasonography in the first trimester? a.Amniotic fluid volume b.Presence of maternal abnormalities c.Placental location and maturity d.Cervical length

ANS: B Ultrasonography can detect certain uterine abnormalities such as bicornuate uterus, fibroids, and ovarian cysts. Amniotic fluid volume, placental location and maturity, and cervical length are not available via ultrasonography until the second or third trimester.

Which nursing intervention is necessary before a first-trimester transabdominal ultrasound? a.Place the woman on nothing by mouth (nil per os [NPO]) for 12 hours. b.Instruct the woman to drink 1 to 2 quarts of water. c.Administer an enema. d.Perform an abdominal preparation

ANS: B When the uterus is still in the pelvis, visualization may be difficult. Performing a first-trimester transabdominal ultrasound requires the woman to have a full bladder, which will elevate the uterus upward and provide a better visualization of the fetus; therefore, being NPO is not appropriate. Neither an enema nor an abdominal preparation is necessary for this procedure.

In the past, factors to determine whether a woman was likely to develop a high-risk pregnancy were primarily evaluated from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted today. Four categories have now been established, based on the threats to the health of the woman and the outcome of pregnancy. Which category should not be included in this group? a.Biophysical b.Psychosocial c.Geographic d.Environmental

ANS: C A geographic category is correctly referred to as sociodemographic risk. These factors stem from the mother and her family. Ethnicity may be one of the risks to pregnancy; however, it is not the only factor in this category. Low income, lack of prenatal care, age, parity, and marital status also are included. Biophysical is one of the broad categories used for determining risk. These include genetic considerations, nutritional status, and medical and obstetric disorders. Psychosocial risks include smoking, caffeine, drugs, alcohol, and psychologic status. All of these adverse lifestyles can have a negative effect on the health of the mother or fetus. Environmental risks are risks that can affect both fertility and fetal development. These include infections, chemicals, radiation, pesticides, illicit drugs, and industrial pollutants.

At 35 weeks of pregnancy, a woman experiences preterm labor. Although tocolytic medications are administered and she is placed on bed rest, she continues to experience regular uterine contractions and her cervix is beginning to dilate and efface. What is an important test for fetal well-being at this time? a.PUBS b.Ultrasound for fetal size c.Amniocentesis for fetal lung maturity d.NST

ANS: C Amniocentesis is performed to assess fetal lung maturity in the event of a preterm birth. The fluid is examined to determine the lecithin to sphingomyelin (L/S) ratio. Indications for PUBS include prenatal diagnosis or inherited blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of the acid-base status of the fetus with IUGR, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. Determination of fetal size by ultrasound is typically performed during the second trimester and is not indicated in this scenario. An NST measures the fetal response to fetal movement in a noncontracting mother.

A client in the third trimester has just undergone an amniocentesis to determine fetal lung maturity. Which statement regarding this testing is important for the nurse in formulating a care plan? a.Because of new imaging techniques, an amniocentesis should have been performed in the first trimester. b.Despite the use of ultrasonography, complications still occur in the mother or infant in 5% to 10% of cases. c.Administration of Rho(D) immunoglobulin may be necessary. d.The presence of meconium in the amniotic fluid is always a cause for concern.

ANS: C As a result of the possibility of fetomaternal hemorrhage, administration of Rho(D) immunoglobulin is the standard of practice after amniocentesis for women who are Rh negative. Amniocentesis is possible after the 14th week of pregnancy when the uterus becomes an abdominal organ. Complications occur in less than 1% of cases; many have been minimized or eliminated through the use of ultrasonography. Meconium in the amniotic fluid before the beginning of labor is not usually a problem.

While working with the pregnant client in her first trimester, what information does the nurse provide regarding when CVS can be performed (in weeks of gestation)? a.4 b.8 c.10 d.14

ANS: C CVS can be performed in the first or second trimester, ideally between 10 and 13 weeks of gestation. During this procedure, a small piece of tissue is removed from the fetal portion of the placenta. If performed after 9 completed weeks of gestation, then the risk of limb reduction is no greater than in the general population.

Which information should nurses provide to expectant mothers when teaching them how to evaluate daily fetal movement counts (DFMCs)? a.Alcohol or cigarette smoke can irritate the fetus into greater activity. b.Kick counts should be taken every hour and averaged every 6 hours, with every other 6-hour stretch off. c.The fetal alarm signal should go off when fetal movements stop entirely for 12 hours. d.A count of less than four fetal movements in 1 hour warrants future evaluation.

ANS: C No movement in a 12-hour period is cause for investigation and possibly intervention. Alcohol and cigarette smoke temporarily reduce fetal movement. The mother should count fetal activity (kick counts) two or three times daily for 60 minutes each time. A count of less than 3 in 1 hour warrants further evaluation by a NST.

A 30-year-old gravida 3, para 2-0-0-2 is at 18 weeks of gestation. Which screening test should the nurse recommend be ordered for this client? a.BPP b.Chorionic villi sampling c.MSAFP screening d.Screening for diabetes mellitus

ANS: C The biochemical assessment MSAFP test is performed from week 15 to week 20 of gestation (weeks 16 to 18 are ideal). A BPP is a method of biophysical assessment of fetal well-being in the third trimester. Chorionic villi sampling is a biochemical assessment of the fetus that should be performed from the 10th to 12th weeks of gestation. Screening for diabetes mellitus begins with the first prenatal visit.

Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy. Which statement regarding monitoring techniques is the most accurate? a.Chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis. b.MSAFP screening is recommended only for women at risk for NTDs. c.PUBS is one of the triple-marker tests for Down syndrome. d.MSAFP is a screening tool only; it identifies candidates for more definitive diagnostic procedures.

ANS: D MSAFP is a screening tool, not a diagnostic tool. CVS provides a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. An MSAFP screening is recommended for all pregnant women. MSAFP screening, not PUBS, is part of the triple-marker tests for Down syndrome.

How does the nurse document a NST during which two or more FHR accelerations of 15 beats per minute or more occur with fetal movement in a 20-minute period? a.Nonreactive b.Positive c.Negative d.Reactive

ANS: D The NST is reactive (normal) when two or more FHR accelerations of at least 15 beats per minute (each with a duration of at least 15 seconds) occur in a 20-minute period. A nonreactive result means that the heart rate did not accelerate during fetal movement. A positive result is not used with NST. CST uses positive as a result term. A negative result is not used with NST. CST uses negative as a result term.

In comparing the abdominal and transvaginal methods of ultrasound examination, which information should the nurse provide to the client? a.Both require the woman to have a full bladder. b.The abdominal examination is more useful in the first trimester. c.Initially, the transvaginal examination can be painful. d.The transvaginal examination allows pelvic anatomy to be evaluated in greater detail.

ANS: D The transvaginal examination allows pelvic anatomy to be evaluated in greater detail than the abdominal method and also allows intrauterine pregnancies to be diagnosed earlier. The abdominal examination requires a full bladder; the transvaginal examination requires an empty one. The transvaginal examination is more useful in the first trimester; the abdominal examination works better after the first trimester. Neither the abdominal nor the transvaginal method of ultrasound examination should be painful, although the woman will feel pressure as the probe is moved during the transvaginal examination.

A woman arrives at the clinic seeking confirmation that she is pregnant. The following information is obtained: She is 24 years old with a body mass index (BMI) of 17.5. She admits to having used cocaine "several times" during the past year and occasionally drinks alcohol. Her blood pressure is 108/70 mm Hg. The family history is positive for diabetes mellitus and cancer. Her sister recently gave birth to an infant with a neural tube defect (NTD). Which characteristics places this client in a high-risk category? a.Blood pressure, age, BMI b.Drug and alcohol use, age, family history c.Family history, blood pressure (BP), BMI d.Family history, BMI, drug and alcohol abuse

ANS: D The woman's family history of an NTD, her low BMI, and her drug and alcohol use abuse are high risk factors of pregnancy. The woman's BP is normal, and her age does not put her at risk. Her BMI is low and may indicate poor nutritional status, which is a high risk.