Maternal Newborn Ch. 19 NCLEX

2. 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. Ultrasound. b. Alpha-fetoprotein (AFP). c. Contraction stress test (CST). d. Amniocentesis.

ANS: A 2. Ultrasound. Rationale: An ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding. The ability to see the lower portion of the uterus and cervix with ultrasound is particularly important when vaginal bleeding is noted and placenta previa is the suspected cause. Alpha-fetoprotein (AFP) is a test used to screen for neural tube defects. A contraction stress test is ordered in the third trimester to evaluate the respiratory function of the placenta. Amniocentesis is a procedure used for genetic diagnosis or, in later pregnancy, for lung maturity studies.

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

ANS: A 6. A client with intrauterine growth retardation. Rationale: A contraction stress test (CST) is indicated for a client with intrauterine growth retardation (IUGR), because it will assess the respiratory function of the placenta, which can be adversely affected by the conditions causing IUGR. The CST is contraindicated in third-trimester bleeding from placenta previa or marginal abruptio placentae, previous cesarean with classical incision (vertical incision in the fundus of the uterus), premature rupture of the membranes, incompetent cervix, anomalies of the maternal reproductive organs, history of preterm labor (if being done prior to term), or multiple gestation.

1. A client at 28 weeks' gestation is admitted to the labor and birth unit. Which test would most likely be used to assess the client's comprehensive fetal status? a. Amniocentesis. b. Biophysical profile (BPP). c. Nonstress test (NST). d. Ultrasound for physical structure.

ANS: B 1. Biophysical profile (BPP). Rationale: Biophysical profile is a comprehensive test that would be used to assess the client's fetal status at 28 weeks' gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well-being. Women with a high risk factor will probably begin having NSTs at 30-32 weeks' gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in pregnancy is used to test for lung maturity, not overall fetal status in labor, and when performed earlier it is used to test for specific disorders.

7. A prenatal client at 22 weeks' gestation is scheduled for an amniocentesis. Which nursing actions would apply to any client undergoing this procedure? Select all that apply. a. Assess vital signs and fetal heart rate. b. Assess for bleeding. c. Administer Rh immune globulin to the client. d. Cleanse the skin with alcohol.

ANS: B, A 7. Assess for bleeding. Assess vital signs and fetal heart rate. Rationale: The skin is cleaned with a Betadine solution. The use of a local anesthesia at the needle insertion site is optional. A 22-gauge needle is then inserted into the uterine cavity, and amniotic fluid is withdrawn (Figure 21-20). After 15-20 mL of fluid has been removed, the needle is withdrawn and the site is assessed for streaming (movement of fluid), which is an indication of bleeding. The fetal heart rate and maternal vital signs are then assessed. Rh immune globulin is given only to all Rh-negative women.

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

ANS: B, C, A 9. Intrauterine infection. Rupture of membranes. Spontaneous abortion. Rationale: Risks of CVS include failure to obtain tissue, rupture of membranes, leakage of amniotic fluid, bleeding, intrauterine infection, maternal tissue contamination of the specimen, and Rh alloimmunization. CVS testing has a higher rate of spontaneous abortion than does amniocentesis. Other complications include fetal limb defects and abnormalities of the fetal face and jaw (March of Dimes, 2003).

4. A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse's response is based on her knowledge that the advantages of ultrasound include which of the following? Select all that apply. a. 'The ultrasound is the only test to determine gender." b. "It is noninvasive and painless." c. "It can be used to estimate gestational age." d. "Results are immediate."

ANS: B, C, D 4. "It is noninvasive and painless." "It can be used to estimate gestational age." "Results are immediate." Rationale: The ability to establish fetal age accurately by ultrasound is lost in the third trimester because fetal growth is not as uniform then as it is in the first two trimesters; however, ultrasound can be used to approximate gestational age within 1-3 weeks' accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.

10. A prenatal client at 35 weeks' gestation is scheduled for an amniocentesis to determine fetal lung maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be: a. 1:1. b. 3:1. c. 2:1. d. 0.5:1.

ANS: C 10. 2:1. Rationale: Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low. (Lecithin levels are low and sphingomyelin levels are high.) At about 32 weeks' gestation, sphingomyelin levels begin to fall and the amount of lecithin begins to increase. By 35 weeks' gestation, an L/S ratio of 2:1 (also reported as 2.0) is usually achieved in the normal fetus.

5. 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. Measure the fetus's biparietal diameter. b. Determine the gestational sac volume. c. Locate the placenta. d. Measure the fetus's crown-rump length.

ANS: C 5. Locate the placenta. Rationale: During an amniocentesis, the physician scans the uterus using ultrasound to identify the fetal and placental positions and to identify adequate pockets of amniotic fluid. Determination of the gestational sac volume, measuring the crown-rump length, and measuring the biparietal diameter are aspects of assessing fetal well-being (biophysical profile, or BPP), and might or might not be done prior to the amniocentesis, depending on gestational age.

8. 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 determine which of the following? Select all that apply. a. Accelerations of fetal heart rate. b. Fetal lung maturity. c. Adequate fetal oxygenation. d. Fetal well-being.

ANS: C, A, D 8. Adequate fetal oxygenation. Accelerations of fetal heart rate. Fetal well-being. Rationale: An NST documents fetal well-being by measuring fetal oxygenation and fetal heart rate accelerations, but not fetal lung maturity.

3. The nurse is preparing a prenatal client for a transabdominal ultrasound. What nursing action should the nurse include in the preparations? Select all that apply. a. Advise the client 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 a side lying position.

ANS:B, C 3. Encourage the client to drink 1.5 quarts of fluid. Apply transmission gel over the client's abdomen. Rationale: After having the client void, assist her to a lithotomy position for a transabdominal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client's abdomen.