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N306 week 2 Test With
Complete Solution
Anencephaly - ANSWER congenital deformity in which some or all of fetal brain is missing Not incompatible with life but severely limiting depending on the stage Iniencephaly - ANSWER a rare neural tube defect in which the brain tissue protrudes through a fissure in the occiput, so that the brain and the spinal cord occupy a single cavity Usually incompatible with life umbilical artery doppler flow - ANSWER identifies heart rate, cardiac defects, placental perfusion and to identify whether its a three vessel cord biochemical assessment - ANSWER invasive test chronic villi sampling - ANSWER performed at 10-12 weeks done transvaginal or abdomen amniocentesis - ANSWER needle puncture of the amniotic sac to withdraw amniotic fluid for analysis when mother is over 35 and + screening for alpha-fetoprotein (AFP) testing for abnormalities, lung maturity, and fetal hemolytic disease amniocentesis - ANSWER nursing interventions:
-bladder needs to be empty -perform NST at least 20-40 min Percutaneous Umbilical Blood Sampling (PUBS) - ANSWER sample of fetal blood from umbilical vein performed at 18 weeks gestation ultrasound guided, results in 48 hours Percutaneous Umbilical Blood Sampling (PUBS) - ANSWER testing is done if detected: -hematologic issues or genetic history -metabolic issues -fetal infection Alfa fetoprotein (AFP) - ANSWER also called maternal serum alpha-fetoprotein (MSAFP) Alfa fetoprotein (AFP) - ANSWER maternal blood sample usually done between 15-20 weeks gestation -high false-positive rate -testing for neural tube defects -genetic testing (trisomy 21) Alfa fetoprotein (AFP) - ANSWER 80-85% neuro tube defects and 90% abdominal wall defects can be detected early in pregnancy multiple marker screen - ANSWER Alpha-fetoprotein, human chorionic
stress of uterine contractions that may induce recurrent episodes of fetal hypoxia. Positive CST results - ANSWER -late decels with 50% uterine contractions -poor result -fetus cant handle labor Negative CST results - ANSWER -No decels with uterine contractions -fetus is tolerating labor no uterine activity - ANSWER nursing interventions: -1st do nipple stimulation -initiate Pitocin or oxytocin to stimulate 3 contractions within 10-20 min period with an average of 40 second duration Amniotic Fluid Index (AFI) - ANSWER screening tool that measures volume of amniotic fluid, fetal well being, and placental fuction normal amniotic fluid index - ANSWER 8-24cm abnormal amniotic fluid index - ANSWER poly= greater than 24cm oligo= less than 5cm Biophysical Profile (BPP) - ANSWER uses a real-time ultrasound for visualization of physical and physiological characteristics of a fetus. Biophysical Profile (BPP) - ANSWER monitors: -breathing -movement
-muscle tone -heart rate -amniotic fluid (AFI) factors that may trigger labor - ANSWER -maternal factors (dilation, contractions, oxytocin release) -fetal factors (water beaks, calcification on placenta) factors affecting labor - ANSWER 1. powers (contractions)
- passage (pelvis)
- passenger (fetus)
- psyche (the response of a woman)
- position (maternal physical position) cephalic/vertex presentation - ANSWER Head is presenting first. onset of labor - ANSWER cervical dilation and contractions (UCs) in regular intervals -rupture of membranes (ROM/SROM) -bloody show (thinning and dilation of cervix) rupture of membranes (ROM) - ANSWER document: -date/time -amount -color (clear)
internal rotation - ANSWER When the rotation of the fetal head aligns the long axis of the fetal head with the long axis of the maternal pelvis; occurs mainly during the second stage of labor
extension - ANSWER Facilitated by resistance of the pelvic floor that causes the presenting part to pivot beneath the pubic symphysis and the head to be delivered; occurs during the second stage of labor
external rotation - ANSWER During this movement, the sagittal suture moves to a transverse diameter and the shoulders align in the anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis
expulsion - ANSWER The shoulders and remainder of the body are delivered
labor - ANSWER is the process in which the fetus, placenta, and membranes are expelled through the uterus
Medical Doctors - ANSWER deliver 92.1% of births
Certified Nursing Midwives - ANSWER deliver 8.1% of births
first stage of labor - ANSWER divided in to 3 stages: -Latent -active -transition
first stage of labor - ANSWER Assess: -vital signs -FHR/UCs -cervical changes -fetal position and descent
Latent phase of labor - ANSWER Dilation: 0-4cm
effacement: 0-40%
UCs every 5-10 min, mild intensity, lasting 30-45 seconds
mild discomfort (strong cramps)
active phase of labor - ANSWER Averages 3-6 hours
second stage of labor - ANSWER sudden burst of energy, improved focus
perineum flattens with bulging rectum and vagina
increasing urge to push or bear down
third stage of labor - ANSWER separation and expulsion fo placenta/membranes
lasts 5-30 min
retained placenta - ANSWER retention of the placenta beyond 30 minutes after birth
fourth stage of labor - ANSWER beginning of the postpartum period until the 4th hour post delivery
homeostasis occurs (more stable)
episiotomy/laceration repair
inspect placenta
APGAR - ANSWER obtain at 1 minute and again at 5 minutes
appearance, pulse, grimace, activity, respiration
Newborn - ANSWER monitor: -temperature -HR -RR -skin color -LOC -tone -activity
pain of childbirth - ANSWER may result from: -decreased blood supply to the uterus -increased pressure and stretching of the pelvic structures -cervical dilation and stretching
sympathetic nervous system - ANSWER stimulates the fetal heart rate
accelerations - ANSWER shows the fetus has good oxygenation and CNS is intact
variable decelerations - ANSWER shows cord compression
late decelerations - ANSWER shows utero-placental insufficiency
early decelerations - ANSWER shows head compression
(no interventions needed)
absent variability - ANSWER amplitude range undetectable
minimal variability - ANSWER <5 bpm
reasons: baby sleeping, decreased BP, medication, magnesium
moderate variability - ANSWER amplitude range 6-25 bpm
CNS is intact, fetus is well oxygenated
marked variability - ANSWER >25 bpm
neurological deficit, trauma
Category I FHR - ANSWER Normal
- baseline rate 110-160 bpm
- baseline variability moderate -accelerations present or not present -late or variable deceleration absent -early decelerations absent or present
Category III FHR - ANSWER Absent variability with any of the following: -recurrent late decelerations -recurrent variable decelerations -bradycardia -sinusoidal pattern
A nurse is reviewing findings of a clients biophysical profile (BPP). The nurse should expect which of the following variables to be included in the test? - ANSWER -fetal breathing movement -fetal tone -amniotic fluid volume
A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (SCT). Which of the findings are indications for this procedure? - ANSWER -decreased fetal movement -intrauterine growth restriction (IUGR) -post-maturity
Terbutaline (Brethine) - ANSWER Uses to relax uterine smooth muscle to inhibit uterine activity
Category I FHR - ANSWER -baseline 110 -moderate variability -accelerations -early decelerations
Category I FHR - ANSWER -baseline 110/
-moderate variability -late or variable deceleration absent
Category III FHR - ANSWER -absent variability -bradycardia
Category III FHR - ANSWER -absent variability -recurrent late decelerations -recurrent variable decelerations
Category III FHR - ANSWER -absent variability -sinusoidal pattern
