Chapter 13: Pregnancy Risk factors and assessment Flashcards
- A patient arrives at the clinic seeking confirmation that they are pregnant. The following information is obtained: They are 24 years old with a body mass index (BMI) of 17.5. They indicate that they have used cocaine “several times” during the past year and drinks alcohol occasionally. Their blood pressure (BP) is 108/70 mm Hg, pulse rate is 72 beats/min, and respiratory rate is 16 breaths/min. The family history is positive for diabetes mellitus and cancer. Their sister recently gave birth to an infant with a neural tube defect (NTD). Which characteristics place the patient in a high risk category?
a. Blood pressure, age, BMI
b. Drug and alcohol use, age, family history
c. Family history, blood pressure, respiratory rate
d. Family history, BMI, drug and alcohol use
ANS: D
The family history of NTD, low BMI, and substance use are all high risk factors of pregnancy. The patient’s BP is normal, and their age is not a risk factor. Her BMI is low and may indicate poor nutritional status, which would be a high risk. The patient’s drug and alcohol use and family history also put them in a high-risk category.
- A 39-year-old primigravida thinks that they are about 8 weeks pregnant, although they have had irregular menstrual periods all their life. They have a history of smoking approximately one pack of cigarettes a day, but tells you that they are trying to cut down. Their laboratory data are within normal limits. What diagnostic technique could be used with this pregnant patient at this time?
a. Ultrasound examination
b. First trimester 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 first trimester screening, an amniocentesis, or an NST. First trimester screening is performed at 11 to 14 weeks of gestation, followed by amniocentesis or other diagnostic test if the results are abnormal or if fetal or maternal anomalies are detected. An NST is performed to assess fetal well-being in the third trimester.
- A nurse sees a patient for the first time when they are 30 weeks pregnant. The patient has smoked throughout the pregnancy, and the 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 that is 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 pregnancies that are high risk because of intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labour. Because of the potential risk of inducing labour and causing fetal distress, a CST is not performed on a patient 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 this may be a useful tool at some point later in this patient’s pregnancy, it is not used to diagnose IUGR.
- A 41-week pregnant multigravida presents in the labour and birth unit after a nonstress test indicated that their 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 screening (MSAFP)
d. Percutaneous umbilical blood sampling (PUBS)
ANS: B
Real-time ultrasound permits detailed assessment of the physical and physiological characteristics of the developing fetus and cataloguing of normal and abnormal biophysical responses to stimuli. The 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 occurred earlier in the pregnancy. It is too late in the pregnancy to perform an MSAFP. Furthermore, it 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 the fetus with IUGR, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus.
- At 35 weeks of pregnancy, a patient experiences preterm labour. Although tocolytics are administered and they are limiting activity, they continue to experience regular uterine contractions, and their 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
ANS: C
Amniocentesis would be performed to assess fetal lung maturity in the event of a preterm birth. 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 the fetus with intrauterine growth restriction, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. Typically, fetal size is determined by ultrasound during the second trimester and is not indicated in this scenario. A nonstress test measures the fetal response to fetal movement in a nonlabouring patient.
- A 40-year-old patient is 10 weeks pregnant. Which diagnostic tool would a nurse teach the patient about that will be used at this time?
a. Biophysical profile
b. Amniocentesis
c. First trimester screening
d. Transvaginal ultrasound
ANS: D
An ultrasound is the method of biophysical assessment of the infant that would be performed at this gestational age. A biophysical profile would be a method of biophysical assessment of fetal well-being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. First trimester screening is performed from week 11 to week 14 of the gestation.
- A maternal serum alpha-fetoprotein (MSAFP) test indicates an elevated level. It 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
ANS: B
If MSAFP findings are abnormal, follow-up procedures include genetic counselling for families with a history of neural tube defect, repeated AFP, ultrasound examination, and possibly amniocentesis. Indications for use of PUBS include prenatal diagnosis of inherited blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of the acid–base status of fetuses with intrauterine growth restriction, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. A BPP is a method of assessing fetal well-being in the third trimester. Before an amniocentesis is considered, the patient first would have an ultrasound for direct visualization of the fetus.
- A pregnant patient asks a nurse, “My doctor told me that he is concerned about the grade of my placenta because I am overdue. What does that mean?” What is the basis for the nurse’s response?
a. The placenta is given a score that indicates the amount of calcium deposits it has.
The more calcium deposits, the higher the grade.
b. Grading is only done when the placenta isn’t working properly.
c. An amniocentesis will need to be done now to detect if the patient has any
placental damage.
d. There is no need to worry as most pregnant patients have their placenta graded.
ANS: A
An accurate and appropriate basis for the nurse’s response is that the placenta is given a score that indicates the amount of calcium deposits it has. The more calcium deposits, the higher the grade. Saying that the placenta isn’t working properly and that this is the reason for grading assumes that there is a placenta problem, and this needs to be assessed before making any assumptions. An ultrasound, not an amniocentesis, is the method of assessment used to determine placental maturation. Giving a response indicating that there is no need to worry about the grading provides false reassurance and discredits the patient’s concerns.
- A patient is undergoing a nipple-stimulated contraction stress test (CST). They are having contractions that occur every 3 minutes. The fetal heart rate (FHR) has a baseline of approximately 120 beats/min, without any decelerations. How would a nurse document the interpretation of this test?
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.
- A nurse is aware that which is true?
a. More than 20% of pregnancies meet the definition of high risk to either the
mother or the infant.
b. A chief factor in high-risk pregnancies is the number of patients who have no
access to prenatal care.
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
In addition to lack of access to prenatal care, lifestyles that pose health risks also are a concern. The high-risk status for the mother extends through 6 weeks after childbirth. The statement “high-risk pregnancy is less critical a medical concern because of the reduction in family size and the decrease in unwanted pregnancies” has enhanced emphasis on delivering babies safely; however, high-risk pregnancy is still a medical concern. More than 20% of pregnancies do not meet the definition of high risk; the majority of pregnancies are considered low risk.
- What should a nurse be aware of when teaching pregnant patients regarding fetal movement counts?
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. All patients should do fetal movement counting daily.
d. If six movements are not felt in 2 hours, further evaluation is required
ANS: D
If at least six movements are not felt in 2 hours, further evaluation of the mother and fetus is required. Alcohol and cigarette smoke temporarily reduce fetal movement. Daily fetal movement counts should be done by patients who perceive decreased movement or have risk factors. The patient gets into a reclined position and counts movements over a 2-hour period.
- In comparing the abdominal and transvaginal methods of ultrasound examination, what should a nurse explain to the patient?
a. Both require the patient 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 also allows intrauterine pregnancies to be diagnosed earlier. The abdominal examination requires a full bladder; the transvaginal examination requires an empty one. 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 patient will feel pressure as the probe is moved.
- A nurse teaches a pregnant patient that ultrasound in the first trimester is best used to assess what information?
a. Amniotic fluid volume
b. Nuchal translucency
c. Placental location and maturity
d. Cervical length
ANS: B
In the first trimester, ultrasonography can be used to assess nuchal translucency and can also detect certain uterine abnormalities, among other uses. Information about amniotic fluid volume, placental location and maturity, and cervical length would not be available via ultrasonography until the second or third trimester.
- What should a nurse teach a patient regarding a biophysical profile (BPP)?
a. It’s an accurate indicator of fetal well-being.
b. It’s a compilation of health risk factors of the mother during the later stages of
pregnancy.
c. It consists of a Doppler blood flow analysis and an amniotic fluid index.
d. It involves an invasive form of ultrasonic examination.
ANS: A
The BPP is an evaluation of current fetal well-being. An abnormal BPP score is one indication that labour should be induced. The BPP is used to evaluate the health of the fetus, requires many different measures, and is a noninvasive procedure.
- What should a nurse be aware of with regard to amniocentesis?
a. Because of new imaging techniques, it is now possible in the first trimester.
b. Complications occur in the mother or infant in 5% to 10% of cases.
c. It allows accurate assessment of fetal lung maturity late in pregnancy.
d. It is only reliable in the third trimester.
ANS: C
Late in pregnancy accurate assessment of fetal lung maturity is possible by examining amniotic fluid for the presence of phosphatidylglycerol (PG) or determination of the L/S ratio. Amniocentesis is possible after the fourteenth week of pregnancy when the uterus becomes an abdominal organ. Complications occur in less than 1% of cases; many have been minimized or eliminated through the use of ultrasonography.
