Unit 2 | Ch. 10 - Assessment of High-Risk Pregnancy

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? The best response by the nurse is: a. Your placenta changes as your pregnancy progresses, and it is given a score that indicates the amount of calcium deposits it has. The more calcium deposits, the higher the grade, or number, that is assigned to the placenta. It also means that less blood and oxygen can be delivered to your baby. b. Your placenta isnt working properly, and your baby is in danger. c. This means that we will need to perform an amniocentesis to detect if you have any placental damage. d. Dont worry about it. Everything is fine.

A (An accurate and appropriate response is, Your placenta changes as your pregnancy progresses, and it is given a score that indicates the amount of calcium deposits it has. The more calcium deposits, the higher the grade, or number, that is assigned to the placenta. It also means that less blood and oxygen can be delivered to your baby. Although Your placenta isnt working properly, and your baby is in danger may be valid, it does not reflect therapeutic communication techniques and is likely to alarm the client. An ultrasound, not an amniocentesis, is the method of assessment used to determine placental maturation. The response Dont worry about it. Everything is fine is not appropriate and discredits the clients concerns.)

A 39-year-old primigravida thinks that she is about 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, but she tells you that she is trying to cut down. Her laboratory data are within normal limits. What diagnostic technique could be used with this pregnant woman at this time? a. Ultrasound examination b. Maternal serum alpha-fetoprotein (MSAFP) screening c. Amniocentesis d. Nonstress test (NST)

A (An ultrasound examination could be done to confirm the pregnancy and determine the gestational age of the fetus. It is too early in the pregnancy to perform MSAFP screening, amniocentesis, or NST. MSAFP screening is performed at 16 to 18 weeks of gestation, followed by amniocentesis if MSAFP levels are abnormal or if fetal/maternal anomalies are detected. NST is performed to assess fetal well-being in the third trimester.)

Compared with contraction stress test (CST), nonstress test (NST) for antepartum fetal assessment: a. Has no known contraindications. b. Has fewer false-positive results. c. Is more sensitive in detecting fetal compromise. d. Is slightly more expensive.

A (CST has several contraindications. NST has a high rate of false-positive results, is less sensitive than the CST)

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 other tool would be useful in confirming the diagnosis? a. Doppler blood flow analysis b. Contraction stress test (CST) c. Amniocentesis d. Daily fetal movement counts

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 intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, CST is not performed on a woman whose fetus is preterm. Indications for amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and 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 womans 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. Lecithin/sphingomyelin (L/S) ratio c. Biophysical profile d. Type and crossmatch of maternal and fetal serum

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 biophysical profile 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.)

Intrauterine growth restriction (IUGR) is associated with numerous 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

ABCE (Poor nutrition, maternal collagen disease, gestational hypertension, and smoking all are risk factors associated with IUGR. Premature rupture of membranes is associated with preterm labor, not IUGR.)

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

ABCE (Transvaginal ultrasound is useful in obese women whose thick abdominal layers cannot be penetrated with traditional abdominal ultrasound. This procedure is also used for identifying 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.)

Maternal Assays (Labs)

Alpha-Fetoprotein - screening tool for NTDs in pregnancy, recommended for all pregnant women Multiple Marker Screens - detects fetal chromosomal abnormalities using 2 maternal biochemical markers in the first trimester such as trisomy 21 Coombs Test - screening for Rh incompatibility, detects other antibodies for incompatibility with maternal antigens

Sociodemographic Risk Factors of Pregnancy

Arise from the mother and her family - may place mother and fetus at risk (low income, lack of prenatal care, age, adolescents, mature mothers, parity, marital status, residence, ethnicity)

In the first trimester, ultrasonography can be used to gain information on: a. Amniotic fluid volume. b. Location of Gestational sacs c. Placental location and maturity. d. Cervical length.

B (During the first trimester, ultrasound examination is performed to obtain information regarding the number, size, and location of gestatials sacs; the presence or absence of fetal cardiac and body movements; the presences or absence of uterine abnormalities (e.g., bicornuate)

Maternal serum alpha-fetoprotein (MSAFP) screening indicates an elevated level. MSAFP screening is repeated and again is reported as higher than normal. What would be the next step in the assessment sequence to determine the well-being of the fetus? a. Percutaneous umbilical blood sampling (PUBS) b. Ultrasound for fetal anomalies c. Biophysical profile (BPP) for fetal well-being d. Amniocentesis for genetic anomalies

B (If MSAFP findings are abnormal, follow-up procedures include genetic counseling for families with a history of neural tube defect, repeated MSAFP screening, ultrasound examination, and possibly amniocentesis. Indications for 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 intrauterine growth restriction, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. BPP is a method of assessing fetal well-being in the third trimester. Before amniocentesis is considered, the client first would have an ultrasound for direct visualization of the fetus.)

A 41-week pregnant multigravida presents in the labor and delivery unit after a nonstress test indicated that her fetus could be experiencing some difficulties in utero. Which diagnostic tool would yield more detailed information about the fetus? a. Ultrasound for fetal anomalies b. Biophysical profile (BPP) c. Maternal serum alpha-fetoprotein (MSAFP) screening d. Percutaneous umbilical blood sampling (PUBS)

B (Real-time ultrasound permits detailed assessment of the physical and physiologic characteristics of the developing fetus and cataloging of normal and abnormal biophysical responses to stimuli. 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 been performed earlier in the pregnancy. It is too late in the pregnancy to perform MSAFP screening. Also, MSAFP screening 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 a fetus with IUGR, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus.)

Which nursing intervention is necessary before a second-trimester transabdominal ultrasound? a. Place the woman 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.

B (When the uterus is still in the pelvis, visualization may be difficult. It is necessary to perform the test when the woman has a full bladder, which provides a window through which the uterus and its contents can be viewed. The woman needs a full bladder to elevate the uterus; therefore being NPO is not appropriate. Neither an enema nor an abdominal preparation is necessary for this procedure.)

Biochemical Assessment

Biologic examination and chemical determinations - amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling, maternal blood sampling

At 35 weeks of pregnancy a woman experiences preterm labor. Tocolytics are administered and she is placed on bed rest, but she continues to experience regular uterine contractions, and her cervix is beginning to dilate and efface. What would be an important test for fetal well-being at this time? a. Percutaneous umbilical blood sampling (PUBS) b. Ultrasound for fetal size c. Amniocentesis for fetal lung maturity d. Nonstress test (NST)

C (Amniocentesis would be performed to assess fetal lung maturity in the event of a preterm birth. 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 a fetus with intrauterine growth restriction, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. Typically, fetal size is determined by ultrasound during the second trimester and is not indicated in this scenario. NST measures the fetal response to fetal movement in a noncontracting mother.)

The nurse providing care for the antepartum woman should understand that contraction stress test (CST): a. Sometimes uses vibroacoustic stimulation. b. Is an invasive test; however, contractions are stimulated. c. Is considered negative if no late decelerations are observed with the contractions. d. Is more effective than nonstress test (NST) if the membranes have already been ruptured.

C (No late decelerations is good news. Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by intravenous oxytocin but not if by nipple stimulation and is contraindicated if the membranes have ruptured.)

In the past, factors to determine whether a woman was likely to develop a high risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted today. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the following is not one of these categories? a. Biophysical b. Psychosocial c. Geographic d. Environmental

C (This 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)

Daily Fetal Movement Count

Can be assessed at home and is noninvasive and simple, frequently used to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenated - several different protocols • Count once a day for 60 minutes • Count fetal activity 2 or 3 times daily for 2 hours or until 10 movements are counted • Count all fetal movements in a 12 hour period each day with a minimum of 10 movements counted

Uses of Ultrasonography During Third Trimester

Confirm gestational age, confirm viability, detect macrosomnia, detect congenital anomalies, detect IUGR, determine fetal position, detect placenta previa or abruption, visualization during amniocentesis or external version, biophysical profile, amniotic fluid volume assessment, doppler flow studies, detect placental maturity, evaluate for preterm labor

Uses of Ultrasonography During First Trimester

Confirm pregnancy and viability, determine gestational age, rule out ectopic pregnancy, detect multiple gestation, determine cause of vaginal bleeding, visualization during chorionic villus sampling, detect maternal abnormalities

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 drinks alcohol occasionally. Her blood pressure (BP) is 108/70 mm Hg, her pulse rate is 72 beats/min, and her respiratory rate is 16 breaths/min. 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 place the woman in a high risk category? a. Blood pressure, age, BMI b. Drug/alcohol use, age, family history c. Family history, blood pressure, BMI d. Family history, BMI, drug/alcohol abuse

D (Her family history of NTD, low BMI, and substance abuse all are high risk factors of pregnancy. The womans BP is normal, and her age does not put her at risk. Her BMI is low and may indicate poor nutritional status, which would be a high risk. The womans drug/alcohol use and family history put her in a high risk category, but her age does not. The womans family history puts her in a high risk category. Her BMI is low and may indicate poor nutritional status, which would be high risk. Her BP is normal.)

A 40-year-old woman is 10 weeks pregnant. Which diagnostic tool would be appropriate to suggest to her at this time? a. Biophysical profile (BPP) b. Amniocentesis c. Maternal serum alpha-fetoprotein (MSAFP) screening d. Transvaginal ultrasound

D (Ultrasound would be performed at this gestational age for biophysical assessment of the infant. BPP would be a method of biophysical assessment of fetal well-being in the third trimester. Amniocentesis is performed after the fourteenth week of pregnancy. MSAFP screening is performed from week 15 to week 22 of gestation (weeks 16 to 18 are ideal).)

Common Maternal and Fetal Indications for Antepartum Testing

Diabetes, chronic hypertension, preeclampsia, suspected or confirmed fetal growth restriction, multiple gestation, oligohydraminos, preterm premature rupture of membranes, late-term or poster gestation, previous stillbirth, decreased fetal movement, systemic lupus erythematous, renal disease, cholestasis of pregnancy

Percutaneous Umbilical Blood Sampling

Direct access to the fetal circulation during the second and third trimesters - insertion of needle directly into fetal umbilical vessel under US guidance - used for evaluation of mosaic results found on amniocentesis or CVS, when sample of fetal blood is required, or to assess for fetal anemia, infection, and thrombocytopenia

Nursing Interventions for All Pregnant Women

Education, anticipatory guidance, counseling for family adaptation, assessment, planning of appropriate interventions

Uses of Ultrasonography During Second Trimester

Establish or confirm dates, confirm viability, detect polyhydraminos or oligohydraminos, detect congenital anomalies, detect IUGR, assess placental location, visualization during amniocentesis, evaluate for preterm labor

Biophysical Risk Factors of Pregnancy

Factors that originate within the mother or fetus and affect the development or functioning of either one or both (genetic considerations, nutritional status, medical and obstetric disorders)

Vibroacoustic Stimulation (VAS)

Generally performed in conjunction with NST, uses combination of sound and vibration to stimulate the fetus

Environmental Risk Factors of Pregnancy

Hazards in the workplace and the woman's general environment (environmental chemicals, anesthetic gases, radiation)

Goals for Antepartum Testing

Identify fetuses at risk for injury due to interrupted oxygenation so that permanent injury or death may be prevented and identify appropriately oxygenated fetuses so that unnecessary intervention can be avoided

Diagnostic Ultrasonography

Important, safe technique in antepartum surveillance - provides critical information to HCPs regarding fetal activity and gestational age, normal vs abnormal fetal growth curves, fetal and placental anatomy, fetal well-being, and visual assistance with which invasive tests can be performed more safely - can be produced abdominally or transvaginally

Label of high-risk pregnancy may result in...

Increased sense of vulnerability, stress r/t diagnosis, ambivalence regarding pregnancy, inability to accomplish tasks of parenthood, fearful for well-being of mother

Psychosocial Risk Factors of Pregnancy

Maternal behaviors and adverse lifestyles that have a negative effect on the health of the mother or fetus (smoking, caffeine, alcohol, drugs, psychologic status)

Nonstress Test (NST)

Most common technique for antepartum evaluation of fetus - basis is that the normal fetus produces characteristic HR patterns in response to fetal movement, uterine contractions, or stimulation - vibroacoustic stimulation is often used

Magnetic Resonance Imagine (MRI)

Noninvasive radiologic technique used for obstetric and gynecologic diagnosis - examiner can evaluate fetal structure, overall growth, placenta, quantity of amniotic fluid

Amniocentesis

Performed to obtain amniotic fluid - possible after week 14 of pregnancy when the uterus becomes an abdominal organ and sufficient amniotic fluid is available for testing

Chorionic Villus Sampling

Popular technique for genetic studies in the first trimester - involves removal of a small tissue specimen from the fetal portion of the placenta - can be performed in the first or second trimester ideally between 10-13 weeks of gestation

Indications for Amniocentesis

Prenatal diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, diagnosis of fetal hemolytic disease

Contraction Stress Test (CST)

Provides earlier warning of fetal compromise than NST and produces fewer false-positive results - can be nipple stimulated or oxytocin stimulated

Complications During Amniocentesis

Rarely occur Maternal: leakage of amniotic fluid, hemorrhage, infection, labor, placental abruption, inadvertent damage to intestines or bladder, amniotic fluid embolism Fetal: death, hemorrhage, infection, direct injury