Chapter 10: assessment of high risk pregnancy
A nonstress test (NST) is ordered on a pregnant women at 37 weeks gestation. What are the most appropriate teaching points to include when explaining the procedure to the patient? (Select all that apply) KK. After 20 minutes, a nonreactive reading indicates the test is complete. LL. Vibroacoustic stimulation may be used during the test. MM. Drinking orange juice before the test is appropriate. NN. A needle biopsy may be needed to stimulate contractions. OO. Two sensors are placed on the abdomen to measure contractions and fetal heart tones.
*LL. Vibroacoustic stimulation may be used during the test.* *MM. Drinking orange juice before the test is appropriate.* *OO. Two sensors are placed on the abdomen to measure contractions and fetal heart tones.* Rationale: A nonreactive test requires further evaluation. The testing period is often extended, usually for an additional 20 minutes, with the expectation that the fetal sleep state will change and the test will become reactive. During this time vibroacoustic stimulation (see later discussion) may be used to stimulate fetal activity. Vibroacoustic stimulation is often used to stimulate fetal activity if the initial NST result is nonreactive and thus hopefully shortens the time required to complete the test. Care providers sometimes suggest that the woman drink orange juice or be given glucose to increase her blood sugar level and thereby stimulate fetal movements. Although this practice is common, there is no evidence that it increases fetal activity. A needle biopsy is not part of a NST. The FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or fetal movements. The tracing is observed for signs of fetal activity and a concurrent acceleration of FHR.
The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? P. Doppler blood flow analysis Q. Contraction stress test (CST) R. Amniocentesis S. Daily fetal movement counts
*P. Doppler blood flow analysis* Rationale: 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 intrauterine growth restriction (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.
The nurse is reviewing lab values to determine Rh incompatibility between mother and fetus. The nurse should assess which specific lab result? BB. Indirect Coombs test CC. Hemoglobin level DD. hCG level EE. Maternal serum alpha-fetoprotein (MSAFP)
*BB. Indirect Coombs test* Rationale: The indirect Coombs test is a screening tool for Rh incompatibility. If the maternal titer for Rh antibodies is greater than 1:8, amniocentesis for determination of bilirubin in amniotic fluid is indicated to establish the severity of fetal hemolytic anemia. Hemoglobin reveals the oxygen carrying capacity of the blood. hCG is the hormone of pregnancy. Maternal serum alpha-fetoprotein (MSAFP) levels are used as a screening tool for NTDs in pregnancy
A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): L. sometimes uses vibroacoustic stimulation. M. is an invasive test; however, contractions are stimulated. N. is considered negative if no late decelerations are observed with the contractions. O. is more effective than nonstress test (NST) if the membranes have already been ruptured.
*N. is considered negative if no late decelerations are observed with the contractions.* Rationale: Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by IV oxytocin but not if by nipple stimulation. No late decelerations indicate a positive CST. CST is contraindicated if the membranes have ruptured.
A woman who is at 36 weeks of gestation is having a nonstress test. Which statement by the woman would indicate a correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseous." C. "This test will help to determine if the baby has Down syndrome or a neural tube defect." D. None of the above
*D. None of the above* Rationale: An ultrasound is the test that requires a full bladder. An amniocentesis would be the test that a pregnant woman should be driven home afterward. A maternal alpha-fetoprotein test is used in conjunction with unconjugated estriol levels, and human chorionic gonadotropin helps to determine Down syndrome. The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.
What is an indicator for performing a contraction stress test? D. Increased fetal movement and small for gestational age E. Maternal diabetes mellitus and postmaturity F. Adolescent pregnancy and poor prenatal care G. History of preterm labor and intrauterine growth restriction
*E. Maternal diabetes mellitus and postmaturity* Rationale: Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator. Maternal diabetes mellitus and postmaturity are two indications for performing a contraction stress test. Although adolescent pregnancy and poor prenatal care are risk factors of poor fetal outcomes, they are not indicators for performing a contraction stress test. Intrauterine growth restriction is an indicator; but history of a previous stillbirth, not preterm labor, is the other indicator.
The health care provider has ordered a magnetic resonance imaging (MRI) study to be done on a pregnant patient to evaluate fetal structure and growth. The nurse should include which instructions when preparing the patient for this test? (Select all that apply.) FF. A lead apron must be worn during the test. GG. A full bladder is required prior to the test. HH. An intravenous line must be inserted before the test. II. Jewelry must be removed before the test. JJ. Remain still throughout the test.
*II. Jewelry must be removed before the test.* *JJ. Remain still throughout the test.* Rationale: Magnetic resonance imaging (MRI) is a noninvasive radiologic technique used for obstetric and gynecologic diagnosis. Similar to computed tomography (CT), MRI provides excellent pictures of soft tissue. Unlike CT, ionizing radiation is not used. Therefore vascular structures within the body can be visualized and evaluated without injecting an iodinated contrast medium, thus eliminating any known biologic risk. Similar to sonography, MRI is noninvasive and can provide images in multiple planes, but no interference occurs from skeletal, fatty, or gas-filled structures, and imaging of deep pelvic structures does not require a full bladder. The woman is placed on a table in the supine position and moved into the bore of the main magnet, which is similar in appearance to a CT scanner. Depending on the reason for the study, the procedure may take from 20 to 60 minutes, during which time the woman must be perfectly still except for short respites.
A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? H. Biophysical profile I. Amniocentesis J. Maternal serum alpha-fetoprotein (MSAFP) K. Transvaginal ultrasound
*K. Transvaginal ultrasound* Rationale: A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal). An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women whose thick abdominal layers cannot be penetrated adequately with the abdominal approach.
Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that: T. chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis. U. screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects. V. percutaneous umbilical blood sampling (PUBS) is one of the quad-screen tests for Down syndrome. W. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.
*W. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.* Rationale: CVS does provide a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. MSAFP screening is recommended for all pregnant women. MSAFP, not PUBS, is part of the quad-screen tests for Down syndrome. This is correct. MSAFP is a screening tool, not a diagnostic tool. Further diagnostic testing is indicated after an abnormal MSAFP.
Prior to the patient undergoing amniocentesis, the most appropriate nursing intervention is to: X. administer RhoD immunoglobulin. Y. administer anticoagulant. Z. send the patient for a computed tomography (CT) scan before the procedure. AA. assure the mother that short-term radiation exposure is not harmful to the fetus.
*X. administer RhoD immunoglobulin.* Rationale: Because of the possibility of fetomaternal hemorrhage, administering RhoD immunoglobulin to the woman who is Rh negative is standard practice after an amniocentesis. Anticoagulants are not administered before amniocentesis as this would increase the risk of bleeding when the needle is inserted transabdominally. A CT is not required before amniocentesis, because the procedure is ultrasound guided. The mother is not exposed to radiation during amniocentesis.