Lowdermilk High Risk Prenancy Chapter 26, Chapter 26: Assessment of High Risk Pregnancy

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?

Biophysical profile Incorrect

Amniocentesis

Maternal serum alpha-fetoprotein (MSAFP)

Transvaginal ultrasound

D. Transvaginal ultrasound

Rationale:

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. 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).

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST):

Sometimes uses vibroacoustic stimulation.

Is an invasive test; however, contractions are stimulated.

Is considered to have a negative result if no late decelerations are observed with the contractions.

Is more effective than nonstress test (NST) if the membranes have already been ruptured.

Is considered to have a negative result if no late decelerations are observed with the contractions

Rationale: No late decelerations indicate a positive CST result. Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is performed by IV oxytocin but not if by nipple stimulation. CST is contraindicated if the membranes have ruptured..

In the past, factors to determine whether a woman was likely to have 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. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category?

Biophysical

Psychosocial

Geographic

Environmental

Geographic

Rationale: The fourth category is correctly referred to as the sociodemographic risk category. The 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 are included. Biophysical is one of the broad categories used for determining risk. It includes 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 those that can affect fertility and fetal development. They include infections, chemicals, radiation, pesticides, illicit drugs, and industrial pollutants.

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test?

"I will need to have a full bladder for the test to be done accurately."

"I should have my husband drive me home after the test because I may be nauseated."

"This test will help to determine whether the baby has Down syndrome or a neural tube defect."

"This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

"This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

Rationale: 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. An ultrasound requires a full bladder. An amniocentesis is the test after which a pregnant woman should be driven home. A maternal serum alpha-fetoprotein test is used in conjunction with unconjugated estriol levels and human chorionic gonadotropin helps to detect Down syndrome.

What is an appropriate indicator for performing a contraction stress test?

Increased fetal movement and small for gestational age

Maternal diabetes mellitus and postmaturity

Adolescent pregnancy and poor prenatal care

History of preterm labor and intrauterine growth restriction

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. Although adolescent pregnancy and poor prenatal care are risk factors for poor fetal outcomes, they are not indicators for performing a contraction stress test. Intrauterine growth restriction is an indicator; history of a previous stillbirth, not preterm labor, is another indicator.

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?

Doppler blood flow analysis

Contraction stress test (CST)

Amniocentesis

Daily fetal movement counts

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 pregnancy due to 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 in 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 it may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.

Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that:

Chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis.

Screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects.

Percutaneous umbilical blood sampling (PUBS) is one of the quad-screen tests for Down syndrome.

MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

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. MSAFP is a screening tool, not a diagnostic tool. Further diagnostic testing is indicated after an abnormal result.

When would the best timeframe be to establish gestational age based on ultrasound?

At term

8 weeks

Between 14 and 22 weeks

36 weeks

Between 14 and 22 weeks

Rationale: Ultrasound determination of gestational age dating is best done between 14 and 22 weeks. It is less reliable after that period because of variability in fetal size. Standard sets of measurements relative to gestational age are noted around 10 to after 12 weeks and include crown-rump length (after 10), biparietal diameter (after 12), femur length, and head and abdominal circumferences.

A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count (DFMC). Which instructions could be included in the plan of care? (Select all that apply.)

The fetal alarm signal is reached when there are no fetal movements noted for 5 hours.

The patient can monitor fetal activity once daily for a 60-minute period and note activity.

Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted.

Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.

The patient can monitor fetal activity once daily for a 60-minute period and note activity.

Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted.

Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.

Rationale: The fetal alarm signal is reached when no fetal movements are noted for a period of 12 hours.

A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure? (Select all that apply.)

Perform ultrasound to determine fetal positioning.

Observe the patient for possible uterine contractions.

Administer RhoGAM to the patient if she is Rh negative.

Perform a minicatheterization to obtain a urine specimen to assess for bleeding.

Observe the patient for possible uterine contractions.

Administer RhoGAM to the patient if she is Rh negative.

Rationale: Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of transabdominal needle. There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.

1. 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. Family history, BMI, drug/alcohol abuse

2. 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. Ultrasound examination

3. 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

4. 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. Biophysical profile (BPP)

5. 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 for fetal lung maturity

6.A 30-year-old gravida 3, para 2-0-0-2 is at 18 weeks of gestation. What screening test should be suggested to her?

a. Biophysical profile

b. Chorionic villi sampling

c. Maternal serum alpha-fetoprotein (MSAFP) screening

d. Screening for diabetes mellitus

ANS: C

The biochemical assessment MSAFP test is performed from week 15 to week 20 of gestation (weeks 16 to 18 are ideal).

A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester.

Chorionic villi sampling is a biochemical assessment of the fetus that should be performed from the tenth to twelfth weeks of gestation.

Screening for diabetes mellitus begins with the first prenatal visit.

In the United States today:

a. More than 20% of pregnancies meet the definition of high risk to either the mother or the infant

b. Other than biophysical criteria, sociodemographic factors place both the mother and baby at risk

c. High risk pregnancy status extends from first confirmation of pregnancy to birth

d. High risk pregnancy is less critical a medical concern because of the reduction in family size and the decrease in unwanted pregnancies

ANS: B

Sociodemographic risks include lack of prenatal care, low income, marital status, and ethnicity.

Approximately 500,000 of the 4 million births (12.5%) in the United States are categorized as high risk.

The high risk status for the mother extends through 30 days after childbirth.

The reduction in family size and the decrease in unwanted pregnancies, along with technologic advances that facilitate pregnancies in previously infertile couples and advance the potential of care, have enhanced emphasis on delivering babies safely.

7. 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. Ultrasound for fetal anomalies

8. 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 isn't 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. "Don't worry about it. Everything is fine."

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."

With regard to maternal, fetal, and neonatal health problems, nurses should be aware that:

a. Infection has replaced pulmonary embolism as one of the three top causes of maternal death attributable to pregnancy

b. The leading cause of death in the neonatal period is disorders related to short gestation and low birth weight

c. Factors related to the maternal death rate include age and marital status but not race

d. Antepartum fetal deaths can best be prevented by better recognizing and responding to abnormalities of pregnancy and labor

ANS: D

Medical teams need to be alert to signs of trouble. Race is a factor. African-American maternal mortality rates are more than three times higher than those for Caucasian women.

Infection used to be an important cause of maternal death; it has been replaced by pulmonary embolism.

The leading cause of death in the neonatal period is congenital anomalies.

Race is a factor. African-American maternal mortality rates are more than three times higher than those for Caucasian women.

Of these psychosocial factors, which has the least negative effect on the health of the mother and/or fetus?

a. Moderate coffee consumption

b. Moderate alcohol consumption

c. Cigarette smoke

d. Emotional distress

ANS: A

Birth defects in humans have not been related to caffeine consumption. Pregnant women who consume more than 300 mg of caffeine daily may be at increased risk for miscarriage or intrauterine growth restriction (IUGR).

9. A woman is undergoing a nipple-stimulated contraction stress test (CST). She is having contractions that occur every 3 minutes. The fetal heart rate (FHR) has a baseline of approximately 120 beats/min without any decelerations. The interpretation of this test is said to be:

a. Negative.

b. Positive.

c. Satisfactory.

d. Unsatisfactory.

a. Negative.

10. When nurses help their expectant mothers assess the daily fetal movement counts, they should be aware that:

a. Alcohol or cigarette smoke can irritate the fetus into greater activity.

b. "Kick counts" should be taken every half hour and averaged every 6 hours, with every other 6-hour stretch off.

c. The fetal alarm signal should go off when fetal movements stop entirely for 12 hours.

d. Obese mothers familiar with their bodies can assess fetal movement as well as average-size women.

c. The fetal alarm signal should go off when fetal movements stop entirely for 12 hours.

11. In comparing the abdominal and transvaginal methods of ultrasound examination, nurses should explain to their clients that:

a. Both require the woman to have a full bladder.

b. The abdominal examination is more useful in the first trimester.

c. Initially the transvaginal examination can be painful.

d. The transvaginal examination allows pelvic anatomy to be evaluated in greater detail.

d. The transvaginal examination allows pelvic anatomy to be evaluated in greater detail.

12. In the first trimester, ultrasonography can be used to gain information on:

a. Amniotic fluid volume.

b. the presence of maternal abnormalities

c. Placental location and maturity.

d. Cervical length.

b. the presence of maternal abnormalities

13. Nurses should be aware that the biophysical profile (BPP):

a. Is an accurate indicator of impending fetal well being.

b. Is a compilation of health risk factors of the mother during the later stages of pregnancy.

c. Consists of a Doppler blood flow analysis and an amniotic fluid index.

d. Involves an invasive form of ultrasound examination.

a. Is an accurate indicator of impending fetal well being.

14. With regard to amniocentesis, nurses should be aware that:

a. Because of new imaging techniques, amniocentesis is now possible in the first trimester.

b. Despite the use of ultrasound, complications still occur in the mother or infant in 5% to 10% of cases.

c. Administration RhoD immunoglobulin may be necessary.

d. The presence of meconium in the amniotic fluid is always cause for concern.

c. Administration RhoD immunoglobulin may be necessary.

15. Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that:

a. Chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis.

b. Maternal serum alpha-fetoprotein (MSAFP) screening is recommended only for women at risk for neural tube defects.

c. Percutaneous umbilical blood sampling (PUBS) is one of the triple-marker tests for Down syndrome.

d. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

d. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

16. 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. Has no known contraindications.

17. 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. Is considered negative if no late decelerations are observed with the contractions.

18. A woman has been diagnosed with a high risk pregnancy. She and her husband come into the office in a very anxious state. She seems to be coping by withdrawing from the discussion, showing declining interest. The nurse can best help the couple by:

a. Telling her that the physician will isolate the problem with more tests.

b. Encouraging her and urging her to continue with childbirth classes.

c. Becoming assertive and laying out the decisions the couple needs to make.

d. Downplaying her risks by citing success rate studies.

b. Encouraging her and urging her to continue with childbirth classes.

20. Risk factors tend to be interrelated and cumulative in their effect. While planning the care for a laboring client with diabetes mellitus, the nurse is aware that she is at a greater risk for:

a. Oligohydramnios.

b. Polyhydramnios.

c. Postterm pregnancy.

d. Chromosomal abnormalities.

b. Polyhydramnios.

21. A pregnant woman's biophysical profile score is 8. She asks the nurse to explain the results. The nurse's best response is:

a. "The test results are within normal limits."

b. "Immediate delivery by cesarean birth is being considered."

c. "Further testing will be performed to determine the meaning of this score."

d. "An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding delivery."

a. "The test results are within normal limits."

22. 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. Multiple-marker screening

23. While working with the pregnant woman in her first trimester, the nurse is aware that chorionic villus sampling (CVS) can be performed during pregnancy at:

a. 4 weeks

b. 8 weeks

c. 10 weeks

d. 14 weeks

c. 10 weeks

24. 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. Instruct the woman to drink 1 to 2 quarts of water.

25. The nurse recognizes that a nonstress test (NST) in which two or more fetal heart rate (FHR) accelerations of 15 beats/min or more occur with fetal movement in a 20-minute period is:

a. Nonreactive

b. Positive

c. Negative

d. Reactive

d. Reactive

26. 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

A, B, C, E

27. 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

A, B, C, E

Which assessment is not included in the fetal biophysical profile (BPP)?

a. Fetal movement

b. Fetal tone

c. Fetal heart rate

d. Amniotic fluid index

e. Placental grade

ANS: E

Fetal movement, tone, heart rate, and amniotic fluid index are all assessed in a BPP.

The placental grade is determined by ultrasound (as is a BPP), but it is not included in the criteria of assessment factors for a BPP.