11. Fetal Assessment & Diagnostics

reactive NST

-FHR normal baseline (110-160 bpm) -moderate variability -accelerates at least 15/min for at least 15 sec -occurs 2x during a 20-min period

nonreactive NST

-does not demonstrate at least 2 qualifying accelerations in a 20-min window -further assessment is indicated (contraction stress test, biophysical profile)

contraction stress test (CST)

-monitors FHR -uterus is stimulated to contract with small amounts of oxytocin or nipple stimulation -indicated after a nonreactive NST

nonstress test (NST)

-monitors response of FHR to fetal movement using an ultrasound transducer -lasts 20 min

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result? 1. Normal findings 2. Abnormal findings 3. The need for further evaluation 4. That the findings on the monitor were difficult to interpret

1. Normal findings (A reactive nonstress test is a normal result. To be considered reactive, the baseline must be within normal range (110 to 160 beats/minute with good variability), and there must be 2 or more fetal heart rate accelerations of at least 15 beats/minute, each with a duration of at least 15 seconds, in a 20-minute interval.) NCLEX

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the FHR is 174 beats/min. On the basis of this finding, what is the priority nursing action? 1. document the finding 2. check the mother's heart rate 3. notify the health care provider 4. tell the client that the FHR is normal

3. notify the health care provider (FHR >160 beats/min could indicate fetal distress) NCLEX

A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? A. Alpha-fetoprotein (AFP) B. Lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. Indirect Coombs' teset

B. Lecithin/sphingomyelin (L/S) ratio ATI

A prenatal client at 30 weeks' gestation is scheduled for an amniocentesis to determine fetal lung maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be: a. 0.5:1 b. 1:1 c. 2:1 d. 3:1

b. 1:1 text

amniocentesis

the aspiration of amniotic fluid using a needle

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching? 1. "I should lie on my back to perform the procedure." 2. "I will use a clock or a timer and record the number of movements or kicks." 3. "I should count the fetal movements for 30 to 60 minutes 3 times a day." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

1. "I should lie on my back to perform the procedure." (pt should lie on her side) NCLEX

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider (HCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the HCP has documented the results as negative. How should the nurse interpret this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery

1. A normal test result (negative=normal: indicates that no late decelerations occurred in the FHR, although the fetus was stressed by 3 contractions of at least 40 sec duration in a 10-min period) NCLEX

A nurse is assisting the health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure? 1. Ask the client to urinate. 2. Ask the client to drink 8 oz of water. 3. Locate the fetal heart tones with a fetoscope. 4. Warm the sonogram gel before placing it on the client's abdomen.

1. Ask the client to urinate. NCLEX

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? 1. Maternal infection 2. Gestational hypertension 3. Gestational diabetes mellitus 4. Consumption of recent high-sugar snack

1. Maternal infection (FHR of 180 beats/min could indicate intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes, and consuming a high-sugar diet may affect FHR but are not the most likely causes.) NCLEX

normal fetal heart rate (FHR)

110-160/min

A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? (Select all that apply) 1. "Prematurity risk increases with a positive result." 2. "This test can be used as a screening for spina bifida." 3. "One of the purposes of this test is to determine the sex of my baby." 4. "This test is a screening test, and I will need other testing if I have abnormal results." 5. "This test can indicate if I may be at an increased risk for having a child with Down syndrome."

2. "This test can be used as a screening for spina bifida." 4. "This test is a screening test, and I will need other testing if I have abnormal results." 5. "This test can indicate if I may be at an increased risk for having a child with Down syndrome." NCLEX

A pregnant client in the prenatal clinic is scheduled for a biophysical profile. The client asks the nurse what this test involves. The nurse should make which appropriate response? 1. "This test measures your ability to tolerate the pregnancy." 2. "This test measures amniotic fluid volume and fetal activity." 3. "This test measures your cardiac status and ability to tolerate labor." 4. "This test only measures the amount of amniotic fluid present in the uterus."

2. "This test measures amniotic fluid volume and fetal activity." NCLEX

The goal for a woman with partial premature separation of the placenta is, "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, would indicate that this goal has been achieved? 1. No accelerations of FHR 2. Moderate variability present 3. Variable decelerations present 4. FHR of 170 to 180 beats/min

2. Moderate variability present NCLEX

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate? 1. Document the findings. 2. Notify the health care provider (HCP). 3. Inform the client that everything is normal and fine. 4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.

2. Notify the health care provider (HCP). (FHR should be 110 to 160 beats/min) NCLEX

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 1. "The procedure takes about 2 hours." 2. "It will be necessary to drink 1 to 2 quarts of water before the examination." 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." 4. "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture."

3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." NCLEX

A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching? (Select all that apply) 1. Uterine contractions are stimulated by Leopold's maneuvers. 2. An external fetal monitor is attached, and the woman ambulates on a treadmill until contractions begin. 3. An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. 4. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation. 5. Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions.

3. An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. 4. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation. NCLEX

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? (Select all that apply) 1. Quickening 2. Braxton-Hicks contractions 3. Fetal heart rate of 180 beats/minute 4. Consistent increase in fundal height 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)

3. Fetal heart rate of 180 beats/minute 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP) (Near and at term, normal FHR = 110-160 beats/min. Elevated MSAFP should be followed up with more specialized testing to determine if a neural tube problem exists.) NCLEX

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action? 1. Notify the health care provider. 2. Prepare the client for labor induction. 3. Place the fetal heart monitor on the client in order to do a nonstress test (NST). 4. Provide the client with information regarding warning signs and symptoms of pregnancy and discharge her to home.

3. Place the fetal heart monitor on the client in order to do a nonstress test (NST). (pt's BPP is 8/8 - indicates fetal well-being, but need to complete the BPP by obtaining NST) NCLEX

A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? 1. She will feel some pain during the procedure. 2. She will be placed in a supine left side-lying position. 3. She will feel some pressure when the vaginal probe is moved. 4. She will need to drink 2 quarts of water to attain a full bladder.

3. She will feel some pressure when the vaginal probe is moved. NCLEX

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. strict bed rest is required after the procedure 2. hospitalization is necessary for 24 hr after the procedure 3. an informed consent needs to be signed before the procedure 4. a fever is expected after the procedure because of the trauma to the abdomen

3. an informed consent needs to be signed before the procedure NCLEX

A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? 1. "The test is a procedure that will require an informed consent to be signed." 2. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 3. "The test is done to see if the baby can handle the stress of labor, and medicine is given to make the uterus contract." 4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen." NCLEX

A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response? 1. "Your baby's heart right now consists of two parallel tubes, so we can't hear it today." 2. "Your baby's heart right now is beginning to partition into four chambers and has begun to beat, so we should be able to hear it with a Doppler." 3. "Your baby's heart right now is beginning to partition into four chambers and has begun to beat, so we should be able to hear it with a fetoscope." 4. "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine."

4. "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine." NCLEX

The nurse is reviewing fetal development with a client who is at 36 weeks gestation. Which statements describe the characteristics that develop in a fetus at this time? Select all that apply. 1. Eyelids begin to fuse. 2. Fetal heart begins to beat. 3. The fetal skin is transparent. 4. The fetus weighs approximately 1200 g. 5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1

5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1 NCLEX

A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply) A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Postmaturity D. Placenta previa E. Amniotic fluid emboli

A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Postmaturity ATI

A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (Select all that apply) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume

A. Fetal weight B. Fetal breathing movement C. Fetal tone E. Amniotic fluid volume ATI

A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? A. "You will lay on your right side during the procedure" B. "You should not eat anything for 24 hours prior to the procedure" C. "You should empty your bladder prior to the procedure" D. "The test is done to determine gestational age"

C. "You should empty your bladder prior to the procedure" ATI

A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A. "It is used to stimulate uterine contractions" B. "It will decrease the incidence of uterine contractions" C. "It lulls the fetus to sleep" D. "It awakens a sleeping fetus"

D. "It awakens a sleeping fetus" ATI

The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)? a. A client with a nonreactive NST b. A client with multiple gestation c. A client with an incompetent cervix d. A client with placenta previa

a. A client with a nonreactive NST text

The nurse is teaching a prenatal client about chorionic villus sampling (CVS). The nurse correctly teaches the client that the risks associated with CVS include: (Select all that apply.) a. Intrauterine infection. b. Rupture of membranes. c. Maternal hypertension. d. Spontaneous abortion.

a. Intrauterine infection. b. Rupture of membranes. d. Spontaneous abortion. text

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should pan to prepare the client for which of the following diagnostic tests? a. biophysical profile b. amniocentesis c. cordocentesis d. Kleihauer-Betke test

a. biophysical profile (positive CST = further evaluation is necessary) ATI

A client in her third trimester has come to the clinic for her first prenatal visit. She asks the nurse whether ultrasound can determine the baby's age. What statement by the nurse would be the best response? a. "The accuracy of ultrasound is the same in the first and third trimesters." b. "The estimate of gestational age may vary by 1-3 weeks." c. "A comprehensive ultrasound is needed for accuracy." d. "The ultrasound measures gender, not age."

b. "The estimate of gestational age may vary by 1-3 weeks." text

A prenatal client at 30 weeks' gestation is scheduled for a nonstress test (NST) and asks the nurse, "What is this test for?" The nurse correctly responds that the test is used to identify: (Select all that apply.) a. Fetal lung maturity. b. Adequate fetal oxygenation. c. Accelerations of fetal heart rate. d. Fetal well-being.

b. Adequate fetal oxygenation. c. Accelerations of fetal heart rate. d. Fetal well-being. text

The nurse is caring for a prenatal client at 38 weeks' gestation whose ultrasound reveals polyhydramnios. She complains of shortness of breath and has 2+ pitting edema in her lower extremities. The nurse anticipates preparation for: a. Delivery by cesarean. b. Amniocentesis. c. Intravenous antibiotics. d. Amnioinfusion.

b. Amniocentesis. text

The nurse is counseling a healthy, 22-year-old G1P0 at 8 weeks' gestation about routine prenatal testing. Which tests should the nurse expect to discuss? a. Amniocentesis b. First-trimester combined screening c. Cell-free DNA d. Fetal echocardiogram

b. First-trimester combined screening text

A client at 28 weeks' gestation is admitted to the labor and birth unit for observation after a motor vehicle crash. Which test might be used to assess the client's fetal status? a. Ultrasound for physical structure b. Contraction stress test (CST) c. Biophysical profile (BPP) d. Amniocentesis

c. Biophysical profile (BPP) text

The physician orders an ultrasound for a prenatal client prior to an amniocentesis. The nurse explains to the client that the purpose of the ultrasound is to: a. Determine the gestational sac volume. b. Measure the fetus's crown-rump length. c. Locate the placenta. d. Measure the fetus's biparietal diameter.

c. Locate the placenta. text

A 22-year-old recent immigrant from Central America has scheduled an initial prenatal visit. In addition to routine prenatal screening, what additional test is indicated for her? a. Hepatitis C antibody b. Hemoglobin electrophoresis c. PPD (purified protein derivative) d. Thyroid-stimulating hormone

c. PPD (purified protein derivative) text

A low-risk client calls the nurse at her prenatal office to report that she is not sure whether her baby has moved as much as usual today. What is the best response from the nurse? a. "Its normal for babies to move less as the pregnancy advances." b. "Go to the hospital for a nonstress test." c. "Pay attention to it for the rest of the day and call tomorrow if it's not back to normal." d. "Go lie on your side, count how many times the baby moves in the next 2 hours, and then call me back."

d. "Go lie on your side, count how many times the baby moves in the next 2 hours, and then call me back." text

The nurse is preparing a prenatal client for a transvaginal ultrasound. What nursing action should be included in the preparations? a. Advise the client not to empty her bladder. b. Encourage the client to drink 1.5 quarts of fluid. c. Apply transmission gel over the client's abdomen. d. Place the client in lithotomy position.

d. Place the client in lithotomy position. text

A prenatal client at 22 weeks' gestation is scheduled for an amniocentesis. What would be an appropriate nursing action to prepare this client for the procedure? a. Cleanse the client's abdominal skin with alcohol. b. Administer Rh immune globulin to the client. c. Encourage the client to take fluids. d. Position the client in a left lateral tilt.

d. Position the client in a left lateral tilt. text

A prenatal client in her second trimester is admitted to the maternity unit with painless, bright red vaginal bleeding. What test might the physician order? a. Alpha fetoprotein (AFP) b. Contraction stress test (CST) c. Amniocentesis d. Ultrasound

d. Ultrasound (ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding) text

BPP scoring

each of the 5 components is given a score of either 2 (normal) or 0 (abnormal) -8-10 = normal, low risk of chronic fetal asphyxia -4-6 = abnormal, suspect chronic fetal asphyxia -<4 = abnormal, strongly suspect chronic fetal asphyxia

biophysical profile (BPP)

observation of fetal responses to stimuli 5 components: 1. fetal breathing movements 2. fetal body movements 3. fetal tone 4. amniotic fluid volume 5. NST/FHR