PREGNANCY CHANGES AND FETAL WELL BEING - ATI CH 3 and 6

How is a Biophysical profile (BPP) measured and scored?

A score of 2 for each normal finding, 0 for each abnormal finding: ◯ Reactive FHR (reactive NST) = 2; nonreactive = 0. ◯ Fetal breathing movements (at least 1 episode of greater than 30 seconds duration in 30 min) = 2; absent or less than 30 seconds duration = 0. ◯ Gross body movements (at least 3 body or limb extensions with return to flexion in 30 min) = 2; less than 3 episodes = 0. ◯ Fetal tone (at least 1 episode of extension with return to flexion) = 2; slow extension and flexion, lack of flexion, or absent movement = 0. ◯ Qualitative amniotic fluid volume (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.

Primigravida

A woman in her first pregnancy

Multigravida

A woman who has had two or more pregnancies

Nulligravida

A woman who has never been pregnant

A nurse in a prenatal clinic is orienting a recently hired nurse about how to perform a nonstress test (NST). What should be included in the orientation? Use the ATI Active Learning Template: Diagnostic Procedure to complete this item to include the following: A. Indications: Identify three that relate to the status of the fetus.

A. Indications: ● Assessment for intact fetal CNS during the third trimester ● Rule out fetal death in a client who has diabetes mellitus ● Decreased fetal movement ● Intrauterine growth restriction ● Postmaturity

A nurse is caring for a client who is in the fourth week of gestation. The client asks about skin and breast changes that can occur during pregnancy. What is an appropriate response by the nurse? Use the ATI Active Learning Template: Basic Concept to complete this item to include the following: A. Related Content: Describe at least three changes that occur to skin and breasts during pregnancy. B. Underlying principles: Describe the basis for these changes.

A. Related Content ● Skin changes: hyperpigmentation; linea nigra; chloasma (mask of pregnancy) on the face; striae gravidarum (stretch marks), most pronounced on abdomen and thighs ● Breast changes: darkening of the areola, enlarged Montgomery's glands, increase in size and heaviness, increased sensitivity B. Underlying principles ● Increase in estrogen and progesterone occurring during pregnancy

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

ANS: A, B, C, D 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.

2. A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply.) A. Client has delivered one newborn at term. B. Client has experienced no preterm labor. C. Client has been through active labor. D. Client has had two prior pregnancies. E. Client has one living child.

ANS: A, D, E A. CORRECT: T1 indicates the client has delivered one newborn at term. B. incorrEct: P0 indicates the client has had no preterm deliveries. C. incorrEct: A1 indicates the client has had one miscarriage. D. CORRECT: G3 indicates the children has had two prior pregnancies and the client is currently pregnant E. CORRECT: L1 indicates the client has one living child.

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

ANS: B 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.

A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following would be included? (Select all that apply.) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening

ANS: B, C, D A. incorrEct: Montgomery's glands are a presumptive sign of pregnancy. B. CORRECT: Goodell's sign is a probable sign of pregnancy. C. CORRECT: Ballottement is a probable sign of pregnancy. D. CORRECT: Chadwick's sign is a probable sign of pregnancy. E. incorrEct: Quickening is a presumptive sign of pregnancy.

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

ANS: B, C, D, E 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.

A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following is an appropriate response by the nurse? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output."

ANS: C A. incorrEct: An increase in blood volume during pregnancy results in cardiac hypertrophy. B. incorrEct: Pressure from the gravid uterus on the diaphragm may cause the client to experience shortness of breath. C. CORRECT: Maternal hypotension occurs when the client is lying in the supine position, and the weight of the gravid uterus places pressure on the vena cava, decreasing venous blood flow to the heart. D. incorrEct: An increase in cardiac output during pregnancy results in cardiac hypertrophy.

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."

ANS: C 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.

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."

ANS: D 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.

A nurse in a clinic receives a phone call from a client who believes she is pregnant and would like to be tested in the clinic to confirm her pregnancy. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested." B. "You should be off any medications for 24 hours prior to the test." C. "You should be NPO for at least 8 hours prior to the test." D. "You should collect urine from the first morning void."

ANS: D A. incorrEct: The production of hCG can be detected as early as 7 to 10 days after conception. B. incorrEct: Clients are not advised to stop taking medications in preparation for pregnancy tests. Medications should be reviewed to determine whether they can affect the results. C. incorrEct: Clients are not advised to remain NPO prior to pregnancy testing. Serum or blood tests are not affected by food or fluid intake. D. CORRECT: Urine pregnancy tests should be done on a first-voided morning specimen to provide the most accurate results.

What two primary things does an amniocentesis measure?

Alpha-fetoprotein (AFP) Fetal lung maturity

What does Alpha-fetoprotein (AFP) indicate and how are the results AFP interpreted?

Alpha-fetoprotein (AFP) can be measured from the amniotic fluid between 16 and 18 weeks of gestation and may be used to assess for neural tube defects in the fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum. ■ High levels of AFP are associated with neural tube defects, such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), or omphalocele (abdominal wall defect). High AFP levels also may be present with normal multifetal pregnancies. ■ Low levels of AFP are associated with chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydatidiform mole).

Why is a Contraction Stress Test (CST) needed?

Analysis of the FHR response to contractions (which decrease placental blood flow) determines how the fetus will tolerate the stress of labor. A pattern of at least three contractions within a 10-min time period with duration of 40 to 60 seconds each must be obtained to use for assessment data.

CHORIONIC VILLUS SAMPLING

Assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance and analyzed. CVS is a first-trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities. CVS can be performed at 10 to 12 weeks of gestation.

A nurse in a prenatal clinic is orienting a recently hired nurse about how to perform a nonstress test (NST). What should be included in the orientation? Use the ATI Active Learning Template: Diagnostic Procedure to complete this item to include the following: B. Interpretation of findings: Describe a nonreactive NST.

B. Interpretation of findings ● Nonreactive NST: Fetal heart rate does not accelerate by 15 beats/min above the baseline FHR for at least 15 seconds at least two or more times during a period of 20 min.

A nurse in a prenatal clinic is orienting a recently hired nurse about how to perform a nonstress test (NST). What should be included in the orientation? Use the ATI Active Learning Template: Diagnostic Procedure to complete this item to include the following: C. Nursing Actions: Two preprocedures one intraprocedure.

C. Nursing Actions: ● Preprocedure ◯ Seat the client in a reclining chair in a semi-Fowler's or left-lateral position. ◯ Apply conduction gel to the client's abdomen. ◯ Apply the Doppler transducer and the tocotransducer. ● Intraprocedure ◯ Instruct the client to depress the event marker button each time she feels fetal movement.

Probable Signs of Pregnancy

Changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus). Signs can be caused by physiological factors other than pregnancy (pelvic congestion, tumors). ◯ Abdominal enlargement related to changes in uterine size, shape, and position ◯ Hegar's sign - softening and compressibility of lower uterus ◯ Chadwick's sign - deepened violet-bluish color of cervix and vaginal mucosa ◯ Goodell's sign - softening of cervical tip ◯ Ballottement - rebound of unengaged fetus ◯ Braxton Hicks contractions - false contractions; painless, irregular, and usually relieved by walking ◯ Positive pregnancy test ◯ Fetal outline felt by examiner

Presumptive Signs of Pregnancy

Changes that the woman experiences that make her think that she may be pregnant. These changes may be subjective symptoms or objective signs. Signs also may be a result of physiological factors other than pregnancy (peristalsis, infections, and stress). ◯ Amenorrhea ◯ Fatigue ◯ Nausea and vomiting ◯ Urinary frequency ◯ Breast changes - darkened areolae, enlarged Montgomery's glands ◯ Quickening - slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation ◯ Uterine enlargement

Linea nigra

Dark line of pigmentation from the umbilicus extending to the pubic area.

Chadwick's sign

Deepened violet-bluish color of cervix and vaginal mucosa

What are the disadvantages of an NST?

Disadvantages of a NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications, and chronic smoking.

What is the interpretation of findings for PUBS?

Evaluates for isoimmune fetal hemolytic anemia and assesses the need for a fetal blood transfusion.

GTPAL acronym

Gravidity Term births (38 weeks or more) Preterm births (from viability up to 37 weeks) Abortions/miscarriages (prior to viability) Living children

Primipara

Has completed one pregnancy to stage of viability

Multipara

Has completed two or more pregnancies to stage of viability

What are the complications of administering a CST?

Hyperstimulation of the uterus (uterine contraction longer than 90 seconds or more frequent than every 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is unsuccessful. ● Oxytocin (Pitocin) administration CST is used if nipple stimulation fails and consists of the IV administration of oxytocin to induce uterine contractions. ◯ Contractions started with oxytocin may be difficult to stop and can lead to preterm labor.

What nursing interventions should be initiated with a positive CST?

Initiate IV oxytocin administration if nipple stimulation fails to elicit a sufficient uterine contraction pattern. If hyperstimulation of the uterus and/or preterm labor occurs, do the following: ☐ Monitor for contractions lasting longer than 90 seconds and/or occurring more frequently than every 2 min. ☐ Provide administration of tocolytics as prescribed. ☐ Maintain bed rest during the procedure. ☐ Observe the client for 30 min afterward to see that contractions have ceased and preterm labor does not begin.

A nurse is caring for a client who is pregnant and states that her last menstrual period was April 1, 2013. Which of the following is the client's estimated date of delivery?

Jan 8, 2014

Fundal height

Measurement of fundal height in centimeters from the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation).

Nonstress test (NST)

Most widely used technique for antepartum evaluation of fetal well-being performed during the third trimester. It is a noninvasive procedure that monitors response of the FHR to fetal movement. A Doppler transducer, used to monitor the FHR, and a tocotransducer, used to monitor uterine contractions, are attached externally to a client's abdomen to obtain tracing strips. The client pushes a button attached to the monitor whenever she feels a fetal movement, which is then noted on the tracing. This allows a nurse to assess the FHR in relationship to the fetal movement.

What is a Contraction Stress Test (CST)?

Nipple stimulated CST consists of a woman lightly brushing her palm across her nipple for 2 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins. The same process is repeated after a 5-min rest period.

Nullipara

No pregnancy beyond the stage of viability

Gravidity

Number of pregnancies

Parity

Number of pregnancies in which the fetus or fetuses reach viability (approximately 20 weeks) regardless of whether the fetus is born alive

Chloasma

Pigmentation increases on the face.

What complications can arise from the interventions for a positive CST?

Potential for preterm labor

Quad Marker and Alpha-Fetoprotein (AFP) Screening

Quad marker screening - a blood test that ascertains information about the likelihood of fetal birth defects. It does not diagnose the actual defect. It may be performed instead of the maternal serum alpha-fetoprotein yielding more reliable findings. Includes testing for: ■ Human chorionic gonadotropin (hCG) - a hormone produced by the placenta ■ Alpha-fetoprotein (AFP) - a protein produced by the fetus ■ Estriol - a protein produced by the fetus and placenta ■ Inhibin-A - a protein produced by the ovaries and placenta

How is an NST interpreted?

REACTIVE IS GOOD! REACTIVE if the FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/min for at least 15 seconds and occurs two or more times during a 20-min period. NONREACTIVE NST indicates that the fetal heart rate does not accelerate adequately with fetal movement. It does not meet the above criteria after 40 min. If this is so, a further assessment, such as a contraction stress test (CST) or biophysical profile (BPP), is indicated.

Ballottement

Rebound of unengaged fetus

Positive Signs of Pregnancy

Signs that can be explained only by pregnancy. ◯ Fetal heart sounds ◯ Visualization of fetus by ultrasound ◯ Fetal movement palpated by an experienced examiner

Quickening

Slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation

Hegar's sign

Softening and compressibility of lower uterus

Striae gravidarum

Stretch marks most notably found on the abdomen and thighs.

Nägele's rule

Take the first day of the woman's last menstrual cycle, subtract 3 months, and then add 7 days and 1 year, adjusting for the year as necessary.

What are the indications for Lung Test in an amniocentesis and how are the results interpreted?

Tests for fetal lung maturity may be performed if gestation is less than 37 weeks, in the event of a rupture of membranes, for preterm labor, or for a complication indicating a cesarean birth. Amniotic fluid is tested to determine whether the fetal lungs are mature enough to adapt to extrauterine life, or if the fetus will likely have respiratory distress. Determination is made whether the fetus should be removed immediately or if the fetus requires more time in utero with the administration of glucocorticoids to promote fetal lung maturity. ■ Fetal lung tests: ☐ Lecithin/sphingomyelin (L/S) ratio - a 2:1 ratio indicating fetal lung maturity (2.5:1 or 3:1 for a client who has diabetes mellitus). ☐ Presence of phosphatidylglycerol (PG) - absence of PG is associated with respiratory distress

Amniocentesis

The aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus. It may be performed after 14 weeks of gestation.

Percutaneous umbilical blood sampling (PUBS)

The most common method used for fetal blood sampling and transfusion. This procedure obtains fetal blood from the umbilical cord by passing a fine-gauge, fiber-optic scope (fetoscope) into the amniotic sac using the amniocentesis technique. The needle is advanced into the umbilical cord under ultrasound guidance, and blood is aspirated from the umbilical vein.

What are the indications for the use of CVS during pregnancy?

Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality (cannot determine spina bifida or anencephaly)

Doppler ultrasound blood flow analysis

a noninvasive external ultrasound method to study the maternal-fetal blood flow 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.

External abdominal ultrasound

a safe, noninvasive, painless procedure whereby an ultrasound transducer is moved over a client's abdomen to obtain an image. An abdominal ultrasound is more useful after the first trimester when the gravid uterus is larger.

Internal transvaginal ultrasound

an invasive procedure in which a probe is inserted vaginally 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 obese and those in the first trimester to detect an ectopic 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.

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.

What are the complications of an amniocentesis?

■ Amniotic fluid emboli ■ Maternal or fetal hemorrhage ■ Fetomaternal hemorrhage with Rh isoimmunization ■ Maternal or fetal infection ■ Inadvertent fetal damage or anomalies involving limbs ■ Fetal death ■ Inadvertent maternal intestinal or bladder damage ■ Miscarriage or preterm labor ■ Premature rupture of membranes ■ Leakage of amniotic fluid

What are the potential diagnoses of a NST during pregnancy?

■ Assessing for an intact fetal CNS during the third trimester. ■ Ruling out the risk for fetal death in clients who have diabetes mellitus. Used twice a week or until after 28 weeks of gestation.

What are the nursing actions for a transvaginal ultrasound?

■ Assist the client into a lithotomy position. The vaginal probe is covered with a protective device, lubricated with a water-soluble gel, and the client or examiner inserts the probe. ■ 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.

Indications for the use of an ultrasound during pregnancy and potential diagnoses for:

■ Confirming pregnancy ■ Confirming gestational age by biparietal diameter (side-to-side) measurement ■ Identifying multifetal pregnancy ■ Site of fetal implantation (uterine or ectopic) ■ Assessing fetal growth and development ■ Assessing maternal structures ■ Confirming fetal viability or death ■ Ruling out or verifying fetal abnormalities ■ Locating the site of placental attachment ■ Determining amniotic fluid volume ■ Fetal movement observation (fetal heartbeat, breathing, and activity) ■ Placental grading (evaluating placental maturation) ■ Adjunct for other procedures (e.g., amniocentesis, biophysical profile)

What are the indications for the use of an NST during pregnancy?

■ Decreased fetal movement ■ Intrauterine growth restriction ■ Postmaturity ■ Gestational diabetes mellitus ■ Gestational hypertension ■ Maternal chronic hypertension ■ History of previous fetal demise ■ Advanced maternal age ■ Sickle cell disease ■ Isoimmunization

What are the nursing actions for an ultrasound?

■ Explain the procedure to the client and that it presents no known risk to her or her fetus. ■ Advise the client to drink 1 to 2 quarts of fluid prior to the ultrasound to fill the bladder, lift and stabilize the uterus, displace the bowel, and act as an echolucent to better reflect sound waves to obtain a better image of the fetus. ■ Assist the client into a supine position with a wedge placed under her right hip to displace the uterus (prevents supine hypotension). ■ Apply an ultrasonic/transducer gel to the client's abdomen before the transducer is moved over the skin to obtain a better fetal image, ensuring that the gel is at room temperature or warmer. ■ Allow the client to empty her bladder at the termination of the procedure.

What are the nursing actions before and during an amniocentesis?

■ Explain the procedure to the client, and obtain INFORMED CONSENT. ■ Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture. ■ Obtain client's baseline vital signs and FHR, and document prior to the procedure. ■ Assist client into a supine position, and place a wedge under her right hip to displace the uterus off the vena cava, and place a drape over the client exposing only her abdomen. ■ Prepare client for an ultrasound to locate the placenta. ■ Cleanse client's abdomen with an antiseptic solution prior to the administration of a local anesthetic by the provider. ■ Advise the client that she will feel slight pressure as the needle is inserted. She should continue breathing because holding her breath will lower the diaphragm against the uterus and shift the intrauterine contents.

What are the indications for the use of PUBS?

■ Fetal blood type, RBC, and chromosomal disorders ■ Karyotyping of malformed fetuses ■ Fetal infection ■ Altered acid-base balance of fetuses with IUGR

What are the indications for the use of a contraction stress test during pregnancy?

■ High-risk pregnancies (gestational diabetes mellitus, postterm pregnancy) ■ Nonreactive stress test ■ Decreased fetal movement ■ Intrauterine growth restriction ■ Postmaturity ■ Gestational diabetes mellitus ■ Gestational hypertension ■ Maternal chronic hypertension ■ History of previous fetal demise ■ Advanced maternal age ■ Sickle-cell disease

What are the nursing actions after an amniocentesis?

■ Monitor the client's vital signs, FHR, and uterine contractions throughout and 30 min following the procedure. ■ Have the client rest for 30 min. ■ Administer RhO(D) immune globulin (RhOGAM) to the client if she is Rh-negative (standard practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization). ■ Advise the client to report to her provider if she experiences fever, chills, leakage of fluid, or bleeding from the insertion site, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure. ■ Encourage the client to drink plenty of liquids and rest for the 24 hr postprocedure.

What are the nursing actions when administering a CST?

■ Obtain a baseline of the FHR, fetal movement, and contractions for 10 to 20 min, and document. ■ Explain the procedure to the client, and obtain informed consent. ■ Complete an assessment without artificial stimulation if contractions are occurring spontaneously. ■ Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. The client should stop when a uterine contraction begins. ■ Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus.

What are the indications for the use of Quad Marker and Alpha-Fetoprotein (AFP) Screening?

■ Preferred at 16-18 weeks gestation ■ Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality

What are the indications for the use of an amniocentesis during pregnancy?

■ Previous birth with a chromosomal anomaly ■ A parent who is a carrier of a chromosomal anomaly ■ A family history of neural tube defects ■ Prenatal diagnosis of a genetic disorder or congenital anomaly of the fetus ■ Alpha fetoprotein level for fetal abnormalities ■ Lung maturity assessment ■ Fetal hemolytic disease ■ Meconium in the amniotic fluid

What are the nursing actions for an NST?

■ Seat the client in a reclining chair, or place in a semi-Fowler's or left-lateral position. ■ Apply conduction gel to the client's abdomen. ■ Apply two belts to the client's abdomen, and attach the FHR and uterine contraction monitors. ■ Instruct the client to press the button on the handheld event marker each time she feels the fetus move. ■ If there are no fetal movements (fetus sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus.

What are the complications in the use of CVS during pregnancy?

■ Spontaneous abortion (higher risk with CVS than with amniocentesis) ■ Risk for fetal limb loss ■ Miscarriage ■ Chorioamnionitis and rupture of membranes *The advantage of an earlier diagnosis should be weighed against the increased risk of fetal anomalies and death.

Indications for the use of an ultrasound during pregnancy when a client presents with:

■ Vaginal bleeding evaluation ■ Questionable fundal height measurement in relationship to gestational weeks ■ Reports of decreased fetal movements ■ Preterm labor ■ Questionable rupture of membranes

How are the results of a CST interpreted?

◯ A negative CST (normal finding) is indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR. ◯ A positive CST (abnormal finding) is indicated with persistent and consistent late decelerations on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable deceleration may indicate cord compression, and early decelerations may indicate fetal head compression. Based on these findings, the provider may determine to induce labor or perform a cesarean birth.

What complications can occur from the use of PUBS?

◯ Cord laceration ◯ Preterm labor ◯ Amnionitis ◯ Hematoma ◯ Fetomaternal hemorrhage

What blood studies are done from the cordocentesis (PUBS)?

◯ Kleihauer-Betke test that ensures that fetal blood was obtained. ◯ CBC count with differential. ◯ Indirect Coombs' test for Rh antibodies. ◯ Karyotyping (visualization of chromosomes). ◯ Blood gases.

What are the Interpretation of findings for Quad Marker and Alpha-Fetoprotein (AFP) Screening?

◯ Low levels of AFP may indicate a risk for Down syndrome. ◯ High levels of AFP may indicate a risk for neural tube defects. ◯ Higher levels than the expected reference range of hCG and Inhibin-A indicates a risk for Down syndrome. ◯ Lower levels than the expected reference range of estriol may indicate a risk for Down syndrome.

What are the potential diagnoses for BPP?

◯ Nonreactive stress test ◯ Suspected oligohydramnios or polyhydramnios ◯ Suspected fetal hypoxemia and/or hypoxia

When would a woman need a BPP?

◯ Premature rupture of membranes ◯ Maternal infection ◯ Decreased fetal movement ◯ Intrauterine growth restriction

How are the results of a Biophysical profile (BPP) interpreted?

◯ Total score of 8 to 10 is normal; low risk of chronic fetal asphyxia ◯ 4 to 6 is abnormal; suspect chronic fetal asphyxia ◯ < 4 is abnormal; strongly suspect chronic fetal asphyxia