CH13 Assessment of Fetal Well-Being
A client's amniocentesis results indicate that the fetus is at risk for respiratory distress. What testing values support this clinical decision? Select all that apply. 1. Amniotic glucose level 50 mg/dL 2. Phosphatidylglycerol (PG) negative 3. Lecithin/sphingomyelin (L/S) ratio 1:6 4. Amniotic fluid red blood cell count 5 mg/dL 5. Lamellar body counts (LBCs) 5000/counts/mcL
A client's amniocentesis results indicate that the fetus is at risk for respiratory distress. What testing values support this clinical decision? Select all that apply. 1. Amniotic glucose level 50 mg/dL 2. Phosphatidylglycerol (PG) negative 3. Lecithin/sphingomyelin (L/S) ratio 1:6 4. Amniotic fluid red blood cell count 5 mg/dL 5. Lamellar body counts (LBCs) 5000/counts/mcL
During a home visit the nurse observes a pregnant client assess fetal activity. Which observations indicate that the client understands the correct process for this count? Select all that apply. 1. Sits in a chair 2. Assumes a side-lying position 3. Counts the same time every day 4. Watches television while counting 5. Begins counting 1 hour after a meal
Answer: 2, 3, 5Explanation: 1. The client should be in a side-lying position when assessing fetal activity. 2. A side-lying position is the position for assessing fetal activity. 3. The count should be conducted the same time every day. 4. The environment should be quiet during the count. 5. The count should occur about 1 hour after a meal.
A woman who is at 12 weeks' gestation asks the nurse if she can undergo chorionic villus sampling (CVS) testing in order to determine whether her baby has a neural tube defect. Which response is best? 1. "No, because CVS testing is not performed until after 20 weeks' gestation." 2. "No, because CVS testing alone at any stage cannot detect neural tube defects." 3. "Yes, at 12 weeks' gestation, CVS can be used to diagnose a neural tube defect." 4. "Yes, at 12 weeks' gestation, CVS is combined with amniocentesis to diagnose neural tube defects."
Answer: 2 Explanation: 1. While CVS is typically performed between 10 and 13 weeks' gestation, this test cannot detect neural tube defects. 2. Because CVS testing is performed so early in the pregnancy, it cannot detect neural tube defects. 3. CVS is typically performed between 10 and 13 weeks' gestation; however, CVS does not detect neural tube defects. 4. CVS is typically performed between 10 and 13 weeks' gestation; however, amniocentesis is not performed until 15 weeks' gestation.
A pregnant client is receiving the results of perinatal testing. Which statement indicates that the client understands the test result? 1. "Because my contraction stress test was positive, we know that my baby will tolerate labor well." 2. "The reactive non-stress test means that my baby is not growing because of a lack of oxygen." 3. "My biophysical profile score of 6 points indicates everything being normal and healthy for my baby." 4. "The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby."
Answer: 4 Explanation: 1. A contraction stress test creates mild contractions. The presence of decelerations is termed a positive result and indicates a lack of adequate placental functioning. 2. The non-stress test utilizes external fetal monitoring to assess the fetal heart rate in relationship to fetal movement. When accelerations in the fetal heart rate are associated with fetal movement (a reactive result), the fetus is well oxygenated, and the placenta is functioning well. 3. The biophysical profile score should be 8 (with adequate amniotic fluid) or 10. A score of 6 is abnormal and indicates that further assessment is needed. 4. The Doppler velocimetry test looks at blood flow through the umbilical artery. A normal result indicates there is no vasospasm decreasing blood flow to the placenta; therefore, the baby is getting an adequate blood supply.
During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test and last 20 seconds each. What should the nurse expect the outcome of this test will be? 1. A reactive test 2. A negative test 3. An equivocal test 4. A nonreactive test
Answer: 4 Explanation: 1. A reactive stress test has the expected results of an increase in heart rate of 15 beats per minute for 15 seconds or more. 2. Non-stress tests are scored as either reactive or nonreactive. 3. Non-stress tests are scored as either reactive or nonreactive. 4. In a nonreactive stress test, the reactivity criteria are not met. Since this client experienced a deceleration during the test, this is considered nonreactive.
The nurse is reviewing nursing documentation related to the care of a client who had an amniocentesis. Which nursing note reflects appropriate client care? 1. Prior to discharge, the client demonstrated vaginal spotting. 2. An Rh-positive client received RhoGAM after the amniocentesis. 3. The client was monitored for 30 minutes after completion of the test. 4. The client reported that she takes insulin before each meal and at bedtime.
Answer: 3 Explanation: 1. Vaginal spotting after the amniocentesis is not an expected finding. A client experiencing vaginal bleeding of any amount after amniocentesis requires additional assessment and should not be sent home. 2. Only Rh-negative clients receive RhoGAM after amniocentesis. The Rh-positive client should not ever receive RhoGAM. 3. Twenty to 30 minutes of fetal monitoring is performed to assess for fetal well-being and to rule out injury of the fetus or placenta during the examination. 4. Whether or not a client takes insulin has nothing to do with amniocentesis. This answer does not relate to the question asked.
The nurse is reviewing amniocentesis with a pregnant client. In which order should the nurse explain the steps that will occur during this procedure? 1. Conduct an ultrasound 2. Fetal heart rate assessed 3. Local anesthetic provided 4. Skin cleansed with antiseptic solution 5. Insertion site observed for fluid streaming 6. 22-gauge needle inserted to withdraw amniotic fluid
Answer: 1, 4, 3, 6, 5, 2 Explanation: 1. An ultrasound is performed first to identify amniotic fluid pockets. 2. Fetal heart rate is assessed last. 3. A local anesthetic is provided after the skin is cleansed. 4. Skin is cleansed after the ultrasound. 5. Fluid streaming occurs after the 22-gauge needle is removed. 6. A 22-gauge needle is inserted after the local anesthetic.
How should the nurse interpret a pregnant client's lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid? 1. Fetal lungs are mature. 2. Fetal lungs are still immature. 3. The fetus has a congenital anomaly. 4. The fetus is small for gestational age.
Answer: 1 Explanation: 1. A 2:1 L/S ratio indicates that the risk of respiratory distress syndrome (RDS) is very low and that the fetus's lungs are mature. 2. Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low if the fetus's lungs are immature, which is not the case in this instance. 3. The L/S ratio is not a measurement for congenital anomalies. 4. The L/S ratio is not a measurement for size of the fetus.
A pregnant client's fundal height is 26 cm at 32 weeks' gestation. Why would the healthcare provider schedule this client for sonograms every 2 weeks? 1. Evaluate fetal growth 2. Determine fetal presentation 3. Assess for congenital anomalies 4. Rule out a suspected hydatidiform mole
Answer: 1 Explanation: 1. A person who is at 32 weeks' gestation should measure 32 cm of fundal height. When a discrepancy between fundal height and measurement exists, the purpose of serial ultrasounds is to monitor fetal growth. 2. Fetal presentation would require only one ultrasound. 3. Assessment of anomalies would require only one ultrasound. 4. Ruling out a hydatidiform mole would require only one ultrasound.
The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching had been effective? 1. "I might be able to see who the baby looks like with the ultrasound." 2. "If the ultrasound is normal, it means my baby has no abnormalities." 3. "The nuchal translucency measurement will diagnose Down syndrome." 4. "Measuring the length of my cervix will determine if I will deliver early."
Answer: 1 Explanation: 1. Ultrasounds provide a very clear photo-like image of the fetus, often providing parents the opportunity to identify a familial characteristic such as nose shape. 2. Not all fetal anomalies are detectable by ultrasound. 3. Nuchal translucency measurements are screening, not diagnostic, for trisomies 13, 18, and 21. 4. Transvaginal ultrasound is used to measure the cervical length as a screening for risk of preterm labor. However, a normal-length cervix does not preclude preterm birth.
The nurse is reviewing clients who would benefit from a biophysical profile (BPP). Which clients should the nurse identify as a priority? Select all that apply. 1. A gravida who is postterm 2. A gravida with intrauterine growth restriction 3. A gravida with mild hypertension of pregnancy 4. A gravida who is experiencing nausea and vomiting 5. A gravida who complains of decreased fetal movement for 2 days
Answer: 1, 2, 3, 5 Explanation: 1. The infant who is postterm might be compromised due to placental insufficiency. 2. The infant who has intrauterine growth problems might be compromised due to placental insufficiency. 3. The BPP is indicated when there is risk of placental insufficiency or fetal compromise because of maternal preeclampsia or eclampsia. 4. Maternal nausea and vomiting is not a criterion for a BPP. 5. The gravida who is experiencing decreased fetal movement for 2 days needs assessment of the placenta and the fetus.
The nurse is preparing teaching material on chorionic villus sampling (CVS) for a client who is entering the 10th week of gestation. What risks should the nurse include with this material? Select all that apply. 1. Bleeding 2. Embryonic puncture 3. Intrauterine infection 4. Inability to obtain a tissue sample 5. Inadvertent rupture of the membranes
Answer: 1, 3, 4, 5Explanation: 1. Risks of CVS include bleeding. 2. Embryonic puncture is not a risk associated with CVS. 3. Risks of CVS include intrauterine infection. 4. Risks of CVS include failure to obtain tissue. 5. Risks of CVS include rupture of the membranes.
A client at 20 weeks' gestation is scheduled for a transabdominal ultrasound. What should the nurse instruct this client about the examination? Select all that apply. 1. "The entire procedure takes between 20 and 30 minutes." 2. "Arrive 30 minutes before the examination so pain medication will be effective." 3. "Transmission gel will be spread over the abdomen during the examination." 4. "Use an over-the-counter enema to empty the colon before the examination." 5. "Drink 1.5 quarts of water 2 hours before the exam and refrain from voiding."
Answer: 1, 3, 5Explanation: 1. Ultrasound testing takes 20 to 30 minutes. 2. Ultrasound is a painless noninvasive diagnostic test. No anesthesia or pain medication is required prior to the procedure. 3. Transmission gel is generously spread over the client's abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture of the uterine contents. 4. It is not necessary to have an empty colon for an ultrasound. 5. The bladder must be full for an ultrasound. The client should be instructed to drink 1 to 1.5 quarts of water 2 hours before the examination and refrain from voiding to ensure a full bladder.
The nurse is responding to phone calls. Which call should the nurse return first? 1. 29 weeks' gestation, reports increased fetal movement 2. 37 weeks' gestation, reports no fetal movement for 24 hours 3. 32 weeks' gestation, reports decreased fetal movement for 2 days 4. 35 weeks' gestation, reports decreased fetal movement for 4 hours
Answer: 2 Explanation: 1. Increased fetal movement is not indicative of a problem. 2. A lack of fetal movement in a fetus in the third trimester can indicate fetal hypoxia or fetal death. This client is the highest priority. 3. Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, this client is not the highest priority. 4. Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, 4 hours is a very short amount of time to assess decreased fetal movement.
A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation? 1. There are more than five fetal movements in a 10-minute period. 2. There are more than three uterine contractions in a 6-minute period. 3. The fetal heart rate accelerates when contractions last up to 60 seconds. 4. The fetal heart rate decelerates when three contractions occur within a 10-minute period.
Answer: 2 Explanation: 1. The fetal movement is considered a negative contraction stress test. 2. An equivocal or suspicious test has nonpersistent late decelerations or decelerations associated with hyperstimulation (contraction frequency of every 2 minutes or duration lasting longer than 90 seconds). When this test result occurs, more information is needed. 3. The acceleration of the heart rate is considered a negative contraction stress test. 4. Decelerations are considered a positive contraction stress test.
What should the nurse do when assisting a pregnant client who is having an abdominal ultrasound to determine fetal age? 1. Has the woman empty her bladder before the test begins 2. Assists the woman into a supine position on the examining table 3. Asks the woman to sign an operative consent form prior to the procedure 4. Instructs the woman to eat a fat-free meal 2 hours before the scheduled test time
Answer: 2 Explanation: 1. The recommendation is that the client should have a full bladder to help elevate the uterus out of the pelvic cavity for better visualization. 2. Clients are placed in a supine position on the table. 3. Abdominal ultrasounds are not invasive procedures and do not require a consent form. 4. Dietary intake is not relevant to the ultrasound.
A woman who is at 15 weeks' gestation received normal chorionic villus sampling (CVS) results and abnormal quadruple screen test results. For detection of congenital anomalies, which test should the nurse expect the woman to be offered next? 1. Ultrasound 2. Amniocentesis 3. Non-stress test (NST) 4. Contraction stress test (CST)
Answer: 2 Explanation: 1. While ultrasound has many uses, it is not useful in the diagnosis of congenital anomalies. 2. Women who have a normal CVS and an abnormal quadruple screen test would be offered amniocentesis to screen for congenital anomalies. 3. The non-stress test is used to assess fetal status. 4. The contraction stress test is used to assess fetal status.
A pregnant client is hesitant to have nuchal translucency testing. What should the nurse explain as being the advantages of having this test? Select all that apply. 1. It has a high false-positive rate. 2. It is performed early in the pregnancy. 3. There is no risk of spontaneous abortion. 4. It provides reassurance of the fetus's development. 5. It accurately detects 90% of Down syndrome fetuses.
Answer: 2, 3, 4, 5Explanation: 1. A high false-positive rate would be a disadvantage of this test. 2. Nuchal translucency testing can be performed in the first trimester to determine if a fetus is at risk for chromosomal disorders. 3. Since it is noninvasive, there is no risk of spontaneous abortion. 4. A normal result can provide reassurance to the woman that her baby most likely does not have a chromosomal disorder. 5. Nuchal translucency testing accurately detects 90% of fetuses with Down syndrome.
A woman at 28 weeks' gestation reports not feeling the baby move for over 30 minutes. How should the nurse respond first? 1. "When did you eat last?" 2. "Have you been smoking?" 3. "Your baby might be asleep." 4. "You need to go to the emergency room immediately for further evaluation."
Answer: 3 Explanation: 1. After meals, an infant typically is active and moving. 2. Smoking typically will stimulate the infant. 3. Lack of fetal activity for 30 minutes typically is insignificant and means only that the infant is sleeping. The mother should continue to observe for fetal movements over the next 2.5 hours. If a lack of fetal movements continues, she should contact the healthcare provider. 4. The mother would need to come to be examined if there had been no fetal activity for several hours.
At 32 weeks' gestation, a woman is scheduled for a second non-stress test. Which client response indicates an adequate understanding of this procedure? 1. "I'll have an IV started before the test." 2. "I need to have a full bladder for this test." 3. "I cannot get up and walk around during the test." 4. "I must avoid drinks containing caffeine for 24 hours before the test."
Answer: 3 Explanation: 1. There is no IV needed to administer medications. 2. Clients usually are asked to have their bladders full only for ultrasounds. 3. The purpose of the non-stress test is to determine the results of movement on fetal heart rate. The client will have to lie still on her side during the procedure. 4. Caffeine might cause the infant to be more active and cause the test to go more quickly.