Chapter 10: Assessment of High-Risk Pregnancy Perry: Maternal Child Nursing Care, 6th Edition MULTIPLE CHOICE 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, and BMI b. Drug/alcohol use, age, and family history c. Family history, blood pressure, and BMI d. Family history, BMI, and drug/alcohol abuse ANS: D Her family history of NTD, low BMI, and substance abuse all are high risk factors of pregnancy. The woman’s 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 woman’s drug/alcohol use and family history put her in a high risk category, but her age does not. The woman’s 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 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) ANS: 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 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 ANS: 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 woman’s pregnancy, it is not used to diagnose IUGR. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Health Promotion and Maintenance 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) ANS: 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Health Promotion and Maintenance 5. A 40-year-old woman is 10 weeks pregnant. Which diagnostic tool would be appropriate to suggest to her at this time? a. b. c. d. Biophysical profile (BPP) Amniocentesis Maternal serum alpha-fetoprotein (MSAFP) screening Transvaginal ultrasound ANS: 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 14th week of pregnancy. MSAFP screening is performed from week 15 to week 22 of gestation (weeks 16 to 18 are ideal). PTS: 1 DIF: Cognitive Level: Comprehension MSC: Client Needs: Health Promotion and Maintenance OBJ: Nursing Process: Planning 6. A patient 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.” ANS: 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 isn’t working properly, and your baby is in danger” may be valid, it does not reflect therapeutic communication techniques and is likely to alarm the patient. An ultrasound, not an amniocentesis, is the method of assessment used to determine placental maturation. The response “Don’t worry about it. Everything is fine” is not appropriate and discredits the patient’s concerns. PTS: 1 DIF: Cognitive Level: Application MSC: Client Needs: Health Promotion and Maintenance OBJ: Nursing Process: Planning 7. 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. ANS: A Adequate uterine activity necessary for a CST consists of the presence of three contractions in a 10-minute time frame. If no decelerations are observed in the FHR pattern with the contractions, the findings are considered to be negative. A positive CST indicates the presence of repetitive later FHR decelerations. Satisfactory and unsatisfactory are not applicable terms. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Health Promotion and Maintenance 8. 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. ANS: C No movement in a 12-hour period is cause for investigation and possibly intervention. Alcohol and cigarette smoke temporarily reduce fetal movement. The mother should count fetal activity (“kick counts”) two or three times daily for 60 minutes each time. Obese women have a harder time assessing fetal movement. PTS: 1 DIF: Cognitive Level: Comprehension MSC: Client Needs: Health Promotion and Maintenance OBJ: Nursing Process: Planning 9. In comparing the abdominal and transvaginal methods of ultrasound examination, nurses should explain to their patients 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. ANS: D The transvaginal examination allows pelvic anatomy to be evaluated in greater detail and allows intrauterine pregnancies to be diagnosed earlier. The abdominal examination requires a full bladder; the transvaginal examination requires an empty bladder. The transvaginal examination is more useful in the first trimester; the abdominal examination works better after the first trimester. Neither method should be painful, although with the transvaginal examination the woman feels pressure as the probe is moved. PTS: 1 DIF: Cognitive Level: Knowledge MSC: Client Needs: Health Promotion and Maintenance OBJ: Nursing Process: Planning 10. 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. ANS: B During the first trimester, ultrasound examination is performed to obtain information regarding the number, size, and location of gestational sacs; the presence or absence of fetal cardiac and body movements; the presences or absence of uterine abnormalities (e.g., bicornuate uterus or fibroids) or adnexal masses (e.g., ovarian cysts or an ectopic pregnancy); and pregnancy dating. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 11. Nurses should be aware that the biophysical profile (BPP): a. is an accurate indicator of impending fetal death. 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. ANS: A An abnormal BPP score is an indication that labor should be induced. The BPP evaluates the health of the fetus, requires many different measures, and is a noninvasive procedure. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. 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. ANS: A CST has several contraindications. NST has a high rate of false-positive results, is less sensitive than the CST, and is relatively inexpensive. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. 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. ANS: C No late decelerations are 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. Risk factors tend to be interrelated and cumulative in their effect. While planning the care for a laboring patient 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. ANS: B Polyhydramnios (amniotic fluid >2000 mL) is 10 times more likely to occur in diabetic compared with nondiabetic pregnancies. Polyhydramnios puts the mother at risk for premature rupture of membranes, premature labor, and after birth hemorrhage. Prolonged rupture of membranes, intrauterine growth restriction, intrauterine fetal death, and renal agenesis (Potter syndrome) all put the patient at risk for developing oligohydramnios. Anencephaly, placental insufficiency, and perinatal hypoxia all contribute to the risk for postterm pregnancy. Maternal age older than 35 years and balanced translocation (maternal and paternal) are risk factors for chromosome abnormalities. PTS: 1 DIF: Cognitive Level: Application MSC: Client Needs: Physiologic Integrity OBJ: Nursing Process: Planning 15. 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.” ANS: A The normal biophysical score ranges from 8 to 10 points if the amniotic fluid volume is adequate. A normal score allows conservative treatment of high risk patients. Delivery can be delayed if fetal well-being is indicated. Scores less than 4 should be investigated, and delivery could be initiated sooner than planned. This score is within normal range, and no further testing is required at this time. The results of the biophysical profile are usually available immediately after the procedure is performed. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 16. 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 ANS: 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. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 17. 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. ANS: C CVS can be performed in the first or second trimester, ideally between 10 and 13 weeks of gestation. During this procedure, a small piece of tissue is removed from the fetal portion of the placenta. If performed after 9 completed weeks of gestation, the risk of limb reduction is no greater than in the general population. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 18. Which nursing intervention is necessary before a second-trimester transabdominal ultrasound? a. Place the woman NPO for 12 hours. b. Instruct the woman not void until after the test. c. Administer an enema. d. Perform an abdominal preparation. ANS: 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. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 19. 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. ANS: D The NST is reactive (normal) when two or more FHR accelerations of at least 15 beats/min (each with a duration of at least 15 seconds) occur in a 20-minute period. A nonreactive result means that the heart rate did not accelerate during fetal movement. A positive result is not used with NST. Contraction stress test (CST) uses positive as a result term. A negative result is not used with NST. CST uses negative as a result term. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Intrauterine growth restriction (IUGR) is associated with numerous pregnancy-related risk factors. (Select all that apply.) a. Poor material weight gain b. Chronic maternal infections c. Gestational hypertension d. Premature rupture of membranes e. Smoking ANS: A, B, C, E Poor material weight gain, chronic infections disease, gestational hypertension, and smoking are all risk factors associated with IUGR. Premature rupture of membranes is associated with preterm labor, not IUGR. PTS: 1 DIF: Cognitive Level: Analysis MSC: Client Needs: Health Promotion and Maintenance OBJ: Nursing Process: Diagnosis 2. 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. Establish gestational age b. Obesity c. Fetal abnormalities d. Amniotic fluid volume e. Ectopic pregnancy ANS: A, B, C, E 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 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. PTS: 1 DIF: Cognitive Level: Application MSC: Client Needs: Physiologic Integrity MATCHING OBJ: Nursing Process: Planning Biophysical risks include factors that originate with either the mother or the fetus and affect the functioning of either one or both. The nurse who provides prenatal care should have an understanding of these risk factors. Match the specific pregnancy problem with the related risk factor. a. Polyhydramnios b. Intrauterine growth restriction (maternal cause) c. Oligohydramnios d. Chromosomal abnormalities e. Intrauterine growth restriction (fetoplacental cause) 1. 2. 3. 4. 5. Premature rupture of membranes Advanced maternal age Fetal congenital anomalies Abnormal placenta development Smoking, alcohol, and illicit drug use 1. ANS: C PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance NOT: Each pregnancy problem can be attributed to a number of related risk factors. Polyhydramnios may also be the result of poorly controlled diabetes mellitus. Other maternal causes of IUGR include hypertensive disorders, diabetes, chronic renal disease, vascular disease, thrombophilia, poor weight gain, and cyanotic heart disease. Fetoplacental causes of IUGR may be related to chromosomal abnormalities, congenital malformations, intrauterine infection, or genetic syndromes. Other contributors to oligohydramnios are renal agenesis, prolonged pregnancy, uteroplacental insufficiency, and paternal hypertensive disorders. Although advanced maternal age is a well-known cause of chromosomal abnormalities, other causes include parental chromosome rearrangements and pregnancy with autosomal trisomy. 2. ANS: D PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance NOT: Each pregnancy problem can be attributed to a number of related risk factors. Polyhydramnios may also be the result of poorly controlled diabetes mellitus. Other maternal causes of IUGR include hypertensive disorders, diabetes, chronic renal disease, vascular disease, thrombophilia, poor weight gain, and cyanotic heart disease. Fetoplacental causes of IUGR may be related to chromosomal abnormalities, congenital malformations, intrauterine infection, or genetic syndromes. Other contributors to oligohydramnios are renal agenesis, prolonged pregnancy, uteroplacental insufficiency, and paternal hypertensive disorders. Although advanced maternal age is a well-known cause of chromosomal abnormalities, other causes include parental chromosome rearrangements and pregnancy with autosomal trisomy. 3. ANS: A PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance NOT: Each pregnancy problem can be attributed to a number of related risk factors. Polyhydramnios may also be the result of poorly controlled diabetes mellitus. Other maternal causes of IUGR include hypertensive disorders, diabetes, chronic renal disease, vascular disease, thrombophilia, poor weight gain, and cyanotic heart disease. Fetoplacental causes of IUGR may be related to chromosomal abnormalities, congenital malformations, intrauterine infection, or genetic syndromes. Other contributors to oligohydramnios are renal agenesis, prolonged pregnancy, uteroplacental insufficiency, and paternal hypertensive disorders. Although advanced maternal age is a well-known cause of chromosomal abnormalities, other causes include parental chromosome rearrangements and pregnancy with autosomal trisomy. 4. ANS: E PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance NOT: Each pregnancy problem can be attributed to a number of related risk factors. Polyhydramnios may also be the result of poorly controlled diabetes mellitus. Other maternal causes of IUGR include hypertensive disorders, diabetes, chronic renal disease, vascular disease, thrombophilia, poor weight gain, and cyanotic heart disease. Fetoplacental causes of IUGR may be related to chromosomal abnormalities, congenital malformations, intrauterine infection, or genetic syndromes. Other contributors to oligohydramnios are renal agenesis, prolonged pregnancy, uteroplacental insufficiency, and paternal hypertensive disorders. Although advanced maternal age is a well-known cause of chromosomal abnormalities, other causes include parental chromosome rearrangements and pregnancy with autosomal trisomy. 5. ANS: B PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance NOT: Each pregnancy problem can be attributed to a number of related risk factors. Polyhydramnios may also be the result of poorly controlled diabetes mellitus. Other maternal causes of IUGR include hypertensive disorders, diabetes, chronic renal disease, vascular disease, thrombophilia, poor weight gain, and cyanotic heart disease. Fetoplacental causes of IUGR may be related to chromosomal abnormalities, congenital malformations, intrauterine infection, or genetic syndromes. Other contributors to oligohydramnios are renal agenesis, prolonged pregnancy, uteroplacental insufficiency, and paternal hypertensive disorders. Although advanced maternal age is a well-known cause of chromosomal abnormalities, other causes include parental chromosome rearrangements and pregnancy with autosomal trisomy.
