Maternal Health Nursing Actions

Questions and Answers

What could high levels of alpha-fetoprotein indicate?

Neural tube defects (correct)

Low risk for fetal developmental issues

Chromosomal disorders

Pregnancy complications related to diabetes

Which L/S ratio indicates fetal lung maturity in a non-diabetic client?

2:1 (correct)

4:1

3:1

1:1

What is the significance of the absence of phosphatidylglycerol (PG)?

Associated with respiratory distress (correct)

Signifies low risk for premature birth

Indicates fetal lung maturity

Indicates normal fetal development

In cases of suspected fetal complications, which nursing action is NOT appropriate?

Assign blame for complications Signup and view all the answers

Which complication is directly associated with Rh isoimmunization?

Fetomaternal hemorrhage Signup and view all the answers

Which of the following is a potential outcome of high levels of alpha-fetoprotein?

Omphalocele Signup and view all the answers

Which maternal complication is NOT mentioned in the possible complications list?

Gestational diabetes Signup and view all the answers

What should clients report to their provider after a procedure?

Decreased fetal movement Signup and view all the answers

What is the primary goal of administering glucocorticoids to a client in preterm labor?

Promote fetal lung maturity Signup and view all the answers

What indicates a high risk for fetal respiratory distress?

Absence of phosphatidylglycerol Signup and view all the answers

What indicates a reactive nonstress test (NST)?

Fetal heart rate accelerates at least 15/min for 15 seconds Signup and view all the answers

Which condition is NOT listed as an indication for performing a nonstress test?

Chronic hypertension Signup and view all the answers

What is the primary purpose of a Biophysical Profile (BPP)?

To assess fetal well-being through multiple variables Signup and view all the answers

What nursing action should be taken if there are no fetal movements detected during the nonstress test?

Use vibroacoustic stimulation to awaken the fetus Signup and view all the answers

What score range on a Biophysical Profile indicates low risk for chronic fetal asphyxia?

8 TO 10 Signup and view all the answers

For which of the following patients is a nonstress test indicated?

A patient diagnosed with diabetes mellitus at 30 weeks Signup and view all the answers

Which of the following actions should be done before performing a transvaginal ultrasound?

Assist the client into a lithotomy position Signup and view all the answers

What is the recommended position for a client during a nonstress test?

Semi-Fowler's or left-lateral position Signup and view all the answers

Which fetal response indicates a nonreactive nonstress test?

Absence of heart rate accelerations Signup and view all the answers

A nonreactive nonstress test requires what follow-up assessment?

A contraction stress test (CST) or biophysical profile (BPP) Signup and view all the answers

What is the recommended client position during an abdominal ultrasound?

Supine with knees flexed Signup and view all the answers

Which of the following does NOT represent a consideration for conducting a nonstress test?

Hyperemesis gravidarum Signup and view all the answers

What indicates an abnormal finding in fetal breathing movements during a BPP?

Less than three episodes in 30 minutes Signup and view all the answers

What is the primary purpose of chorionic villus sampling (CVS)?

To obtain a portion of the placenta for genetic testing Signup and view all the answers

Which of the following is a complication associated with chorionic villus sampling?

Rupture of membranes Signup and view all the answers

When is maternal alpha-fetoprotein (MSAFP) screening typically performed during pregnancy?

Preferably between 16 and 18 weeks of gestation Signup and view all the answers

What does a high level of maternal alpha-fetoprotein (MSAFP) indicate?

Neural tube defects or open abdominal defects Signup and view all the answers

What is a critical nursing action to take before performing an amniocentesis?

Empty the client's bladder Signup and view all the answers

What is a significant nursing consideration before performing umbilical cord sampling?

Obtain informed consent and provide education Signup and view all the answers

Which of the following findings could indicate placental insufficiency during the procedure?

Late decelerations in FHR Signup and view all the answers

What should be documented before proceeding with the amniocentesis?

Baseline vital signs and fetal heart rate Signup and view all the answers

What client education should be provided regarding the sensation during needle insertion?

There will be a feeling of slight pressure Signup and view all the answers

Which of the following is NOT a potential indication for performing an amniocentesis?

Current respiratory infection Signup and view all the answers

What should the nurse do to prepare the client for an ultrasound during amniocentesis?

Assist the client into a supine position Signup and view all the answers

What does it indicate if the fetal heart rate does not return to baseline within 15 to 20 minutes after contractions?

Potential fetal distress Signup and view all the answers

What positioning is recommended for the client during the intraprocedure phase of amniocentesis?

Supine position Signup and view all the answers

Which type of deceleration would indicate an urgent need to induce labor?

Late decelerations Signup and view all the answers

During amniocentesis, which instruction should NOT be given to help manage discomfort?

Relax and let the nurse handle everything Signup and view all the answers

What is the primary indication for performing a contraction stress test?

Assessment for fetal distress in high-risk pregnancies Signup and view all the answers

What would suggest a positive contraction stress test?

Late decelerations occurring with 50% or more of the contractions Signup and view all the answers

Which nursing action should be taken first to prepare a client for a contraction stress test?

Explain the procedure and obtain informed consent Signup and view all the answers

What should a nurse monitor for if uterine hyperstimulation occurs during a contraction stress test?

Contractions lasting longer than 90 seconds Signup and view all the answers

Which client presentation is NOT typically an indication for a contraction stress test?

Normal fetal growth trajectory Signup and view all the answers

What complication can arise from the contraction stress test procedure?

Potential for preterm labor Signup and view all the answers

Which fetal heart rate change indicates cord compression during a contraction stress test?

Variable decelerations Signup and view all the answers

Which action is appropriate if nipple stimulation fails to elicit uterine contractions?

Initiate IV oxytocin administration Signup and view all the answers

What describes a negative contraction stress test finding?

No late decelerations within a defined timeframe Signup and view all the answers

Study Notes

Considerations in High-Risk Pregnancy

Premature rupture of membranes can lead to complications.
Maternal infections pose risks to both mother and fetus.
Decreased fetal movement may indicate fetal distress.
Intrauterine growth restriction can signal abnormal fetal development.

Nursing Actions for Ultrasounds

Abdominal Ultrasound

Educate about the non-invasive nature and lack of risk for both mother and fetus.
Advise a full bladder to improve imaging quality.
Position client supine with support for comfort.
Use warmed ultrasonic gel to enhance image acquisition.
Allow bladder emptying post-procedure and provide materials for cleanup.

Transvaginal Ultrasound

Position client in lithotomy for optimal access.
Probe preparation includes a protective covering and lubrication.
Adjust probe position as necessary for thorough examination.
Inform client of potential pressure sensations during the procedure.

Biophysical Profile (BPP)

Utilizes real-time ultrasound to gauge fetal responses and structures.
Combines fetal heart rate monitoring with ultrasound observations.

Indications for BPP

Nonreactive nonstress test results.
Suspected oligohydramnios or polyhydramnios.
Concerns about fetal hypoxemia or hypoxia.

BPP Scoring System

Scores assigned for five variables:
- FHR Reactive (2) / Nonreactive (0)
- Fetal breathing movements (2) / Absent (0)
- Gross body movements (2) / Less than 3 episodes (0)
- Fetal tone (2) / Absent movement or slow (0)
- Amniotic fluid volume (2) / Insufficient pockets (0)
Total Scores:
- 8 to 10 is normal, indicating low risk for chronic fetal distress.
- 4 to 6 is abnormal; further assessment needed.
- Less than 4 suggests strong suspicion of chronic fetal distress.

Reactive Nonstress Test (NST)

Evaluates fetal central nervous system function in the third trimester.
Important for clients with gestational diabetes to assess fetal safety.

Nursing Actions for NST

Prepare client in a semi-reclining position and apply conduction gel.
Attach ultrasound transducer and tocotransducer to monitor fetal heart activity.
Instruct client to mark fetal movements electronically.
Use vibroacoustic stimulation if fetal movements are absent.

Interpretation of NST Findings

Reactive if FHR shows acceleration of at least 15 beats/min for 15 seconds, occurring twice in 20 minutes.
Nonreactive requires follow-up testing such as CST or BPP.

Contraction Stress Test (CST)

Indicated for high-risk pregnancies and nonreactive NST outcomes.

Client Presentation for CST

Signs include decreased fetal movement, intrauterine growth restriction, and conditions such as diabetes or hypertension.

Nursing Actions for CST

Obtain FHR baseline and monitor movements for 10-20 minutes pre-test.
Use nipple stimulation to initiate contractions if needed.
Educate the client about potential sensations during nipple stimulation.
Monitor closely to avoid complications like tachysystole.

Amniocentesis Overview

Procedure involves collecting amniotic fluid for analysis.
Indicated when chromosomal anomalies or fetal disorders are suspected.

Nursing Actions for Amniocentesis

Ensure bladder is emptied before the procedure to minimize risk of puncture.
Maintain client comfort and monitor vitals during the process.
Educate clients to anticipate slight pressure during needle insertion.

Interpretation of Amniocentesis Findings

High alpha-fetoprotein levels suggest neural tube defects.
Low levels may indicate chromosomal disorders like Down syndrome.

High-Risk Pregnancy Testing

Chorionic Villus Sampling (CVS)

Conducted in the first trimester for earlier diagnoses of genetic issues.
Risks include potential miscarriage and fetal limb loss.

Quad Marker Screening

Blood test assessing risk for birth defects, not definitive diagnosis.
Measures hCG, AFP, estriol, and inhibin A.

Maternal Serum Alpha-Fetoprotein (MSAFP)

Screening tool for neural tube defects, preferably performed at 16-18 weeks.

Umbilical Sampling (Cordocentesis)

Analyzes fetal blood for abnormalities, antibodies, and chromosome analysis.

Nursing Interventions and Client Education

Provide emotional support and monitor fetal heart rate following procedures.
Instruct clients to report concerning symptoms post-testing such as fever or decreased movement.

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Description

Explore essential nursing actions for managing maternal complications like premature rupture of membranes, maternal infection, and intrauterine growth restriction. This quiz will test your understanding of abdominal ultrasound procedures and nursing considerations to ensure maternal and fetal well-being.