Chapter 6 Assessment of Fetal Well-Being ATI

1. A nurse is caring for a client and reviewing the findings of the client's biophysical profile (BPP). Which of the following variables are included in this test? (Select all that apply.) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Reactive FHR E. Amniotic fluid volume

1. A. INCORRECT: Fetal weight is not one of the variables included in the BPP. B. CORRECT: Fetal breathing movements are a variable included in the BPP. C. CORRECT: Fetal tone is a variable included in the BPP. D. CORRECT: Reactive FHR is a variable included in the BPP. E. CORRECT: Amniotic fluid volume is a variable included in the BPP.

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

2. A. INCORRECT: AFP is a test to assess for fetal neural tube defects or chromosome disorders. B. CORRECT: A test of the L/S ratio is done as a part of an amniocentesis to determine fetal lung maturity. C. INCORRECT: A Kleihauer-Betke test is used to verify that fetal blood is present during a percutaneous umbilical blood sampling procedure. D. INCORRECT: An indirect Coombs' test detects Rh antibodies in the mother's blood.

3. 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 is an appropriate response by the nurse? 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."

3. A. INCORRECT: The acoustic vibration device does not stimulate the uterus. B. INCORRECT: The acoustic vibration device has no effect on the uterine muscles. C. INCORRECT: The acoustic vibration device stimulates a sleeping fetus. D. CORRECT: The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus.

4. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements by the client requires clarification? A. "I will report cramping or signs of infection to the physician." B. "I should drink lots of fluids during the 24 hours following the procedure." C. "I need to have a full bladder at the time of the procedure." D. "The test is done to detect genetic abnormalities."

4. A. INCORRECT: Cramping and signs of infection following the procedure should be reported to the provider. B. INCORRECT: The client is encouraged to drink extra fluids and rest during the 24 hr following an amniocentesis. C. CORRECT: The client's bladder should be empty to avoid an inadvertent puncture during the procedure. D. INCORRECT: Amniotic fluid is tested to identify fetal genetic defects.

5. 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. Advanced maternal age E. Amniotic fluid emboli

5. A. CORRECT: Decreased fetal movement is an indication for a CST. B. CORRECT: IUGR is an indication for a CST. C. CORRECT: Postmaturity is an indication for a CST. D. CORRECT: Advanced maternal age is an indication for a CST. E. INCORRECT: Amniotic fluid emboli are a complication of an amniocentesis.

Overview ●● Biophysical profile (BPP) - uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. ●● BPP assesses fetal well-being by measuring the following five variables with a score of 2 for each normal finding, and 0 for each abnormal finding for each variable. ◯◯ Reactive __ (reactive nonstress test) = 2; nonreactive = 0. ◯◯ Fetal __ movements (at least 1 episode of greater than 30 seconds duration in 30 min) = 2; absent or less than 30 seconds duration = 0. ◯◯ __ __ __ (at least 3 body or limb extensions with return to flexion in 30 min) = 2; less than 3 episodes = 0. ◯◯ __ __ (at least 1 episode of extension with return to flexion) = 2; slow extension and flexion, lack of flexion, or absent movement = 0. ◯◯ Qualitative __ __ __ (at least 1 pocket of fluid that measures at least 2 cm in 2 perpendicular planes) = 2; pockets absent or less than 2 cm = 0.

FHR breathing Gross body movements Fetal tone amniotic fluid volume

Continue.. ◯◯ Doppler ultrasound blood flow analysis - a noninvasive external ultrasound method to study the maternal-fetal __ __ by measuring the velocity at which RBCs travel in the uterine and fetal vessels using a handheld ultrasound device that reflects sound waves from a moving target. It is especially useful in fetal intrauterine growth restriction (IUGR) and poor placental perfusion, and as an adjunct in pregnancies at risk because of hypertension, diabetes mellitus, multiple fetuses, or preterm labor.

blood flow

Continue.. ◯◯ Internal transvaginal ultrasound - an __ procedure in which a probe is inserted __ to allow for a more accurate evaluation. An advantage of this procedure is that it does not require a full bladder. ■■ It is especially useful in clients who are __ and those in the first trimester to detect an __ pregnancy, identify abnormalities, and to establish gestational age. ■■ A transvaginal ultrasound also may be used in the third trimester in conjunction with abdominal scanning to evaluate for preterm labor.

invasive vaginally obese ectopic

●● Nursing actions for a transvaginal ultrasound ◯◯ Preparation of client ■■ Assist the client into a __ __. The vaginal probe is covered with a protective device, lubricated with a water-soluble gel, and the client or examiner inserts the probe. ◯◯ Ongoing care ■■ During the procedure, the position of the probe or tilt of the table may be changed to facilitate the complete view of the pelvis. ■■ Inform the client that pressure may be felt as the probe is moved. ●● Client education ◯◯ Fetal and maternal structures may be pointed out to the client as the ultrasound procedure is performed.

lithotomy position

●● Client presentation ◯◯ Premature rupture of __ ◯◯ Maternal __ ◯◯ Decreased __ __ ◯◯ __ growth restriction

membranes infection fetal movement Intrauterine

●● Indications for the use of an ultrasound during pregnancy ◯◯ Potential diagnoses for: ■■ Confirming __ ■■ Confirming gestational __ by biparietal diameter (side-to-side) measurement ■■ Identifying __ pregnancy ■■ Site of fetal __ (uterine or ectopic) ■■ Assessing fetal __ and __ ■■ Assessing maternal structures ■■ Confirming fetal viability or death ■■ Ruling out or verifying fetal __ ■■ Locating the site of placental attachment ■■ Determining __ __ __ ■■ Fetal movement observation (fetal heartbeat, breathing, and activity) ■■ Placental grading (evaluating placental maturation) ■■ Adjunct for other procedures (e.g., amniocentesis, biophysical profile)

pregnancy age multifetal implantation growth development abnormalities amniotic fluid volume