Chapter 3: Antenatal Assessment and High Risk Delivery Test Bank

Multiple Choice

1. A pregnant woman has been diagnosed with pregestational diabetes. Which of the following risk factors should the therapist be aware at the time of delivery? a. Unexplained abruption placenta b. Oligohydramnios c. Microcephaly d. Fetal malformations

ANS: C

Adverse fetal outcomes include unexplained fetal death in the third trimester of pregnancy and major fetal structural malformations. Close surveillance of the maternal metabolism and close fetal biophysical evaluation have significantly decreased the risk of fetal death as well as the necessity of delivering a fetus prematurely because of abnormal test results. The rate of fetal structural malformations in infants born to pregestational diabetic women can be as high as 10% to 15% compared with a rate of 1% to 2% for infants of otherwise normal women. The most frequently encountered defects include malformations of the cardiovascular system, including both the heart and great vessels, and the central nervous system, including the brain and spinal cord. No amount of maternal metabolic surveillance or fetal biophysical assessment after the period of fetal organogenesis will decrease this risk. Therefore, it is recommended strongly that women with diabetes mellitus receive counseling and treatment with the goal of achieving optimal glycemic control before they become pregnant.

REF: p. 22

2. The respiratory therapist is attending a term labor of a woman diagnosed with gestational diabetes. The baby is very large for gestational age. What other metabolic disturbances should be considered?

I. Hyperglycemia

II. Hypocalcemia

III. Hyperkalemia

IV. Hypoglycemia a. II and IV only b. I, II, and III only c. I and III only d. II, III, and IV only

ANS: D

Poor blood sugar control in these women is associated with an increased risk of macrosomia (birth weight greater than 4000 g), traumatic vaginal delivery, preterm delivery, and a small risk of fetal death in some women. After delivery, the infants are at increased risk for metabolic disturbances in the neonatal period; these include hypoglycemia, hypocalcemia, hyperkalemia, hyperbilirubinemia, and idiopathic respiratory distress syndrome.

REF: p. 22 a. Group B Streptococcus b. Haemophilus influenzae c. Mycobacterium tuberculosis d. Hepatitis C virus

3. Which of the following microorganisms often affect pregnancy outcome?

ANS: A

A number of infectious agents can affect pregnancy outcome. Among the most important in the United States are group B Streptococcus (GBS), herpes simplex virus (HSV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV). As many as 10% to 40% of pregnant women are colonized with GBS. Their infants are at risk for death or severe morbidity if they are born prematurely or after prolonged rupture of the fetal membranes.

REF: p. 23 a. One to two 8-ounce drinks per day are considered acceptable. b. Four to five 8-ounce drinks per week are considered safe. c. Three to four 12-ounce drinks per week are considered reasonable. d. No safe range of alcohol consumption is deemed safe during pregnancy.

4. What is generally accepted as a safe limit for alcohol consumption during pregnancy to avoid the development of fetal alcohol syndrome?

ANS: D

Alcohol is a potent teratogen, an agent or factor that causes malformation in the fetus. Fetal alcohol syndrome, associated with maternal use of alcohol in pregnancy, is characterized by mental retardation and prenatal and postnatal growth restriction, as well as by brain, cardiac, spinal, and craniofacial anomalies. It is usually seen among children of women who consume four to six alcoholic drinks daily throughout pregnancy. However, no safe range of alcohol consumption during pregnancy exists.

REF: p. 24 a. Infants born of mothers who smoke tend to be about 200 g lighter than infants born of mothers who do not smoke. b. Infants born of mothers who smoke are generally about 400 g lighter than infants born of nonsmoking mothers. c. Infants born of mothers who smoke are predisposed to weigh approximately 600 g less than infants born of mothers who do not smoke. d. Infants of mothers who smoke are likely to be born about 800 g lighter than those born of mothers who do not smoke.

5. What is the average birth weight difference between infants born of mothers who smoke and those born of nonsmoking mothers?

ANS: A

The mean birth weight of infants of women who smoke during pregnancy is about 200 g less than that of infants of nonsmokers.

REF: p. 24

6. A woman with a long history of smoking is now in the last part of the third trimester of her pregnancy. She is at high risk for which of the following conditions?

I. Premature rupture of membranes

II. Placental abruption

III. Placenta previa

IV. Sudden infant death syndromea. II and IV only b. I, II, and III only c. I and III only d. I, II, III, and IV

ANS: D

Smoking is associated with a higher incidence of preterm premature rupture of membranes (rupture of the membranes before the onset of labor before 37 weeks of gestation), placental abruption (separation of the placenta before birth of the newborn), and placenta previa (the placenta partially or completely covers the cervix), and risk of infant death from sudden infant death syndrome, (the unexplained death of an infant under 1 year of age).

REF: p. 24

7. Which of the following conditions are associated with preeclampsia?

I. Multiparity

II. Proteinuria

III. Generalized edemaIV. Hypertension a. II and III b. I, II, and III c. I, III, and IV d. II, III, and IV

ANS: D

Preeclampsia is a pregnancy-specific multisystem disorder traditionally diagnosed as the onset or exacerbation of hypertension, proteinuria, and edema in the second half of pregnancy. It complicates approximately 5% to 8% of pregnancies.

REF: p. 24

8. What is the main potential problem associated with the premature rupture of membranes? a.

Fetal dehydration b. Fetal infection c. Maternal hypotension d. Maternal renal failure

ANS: B

In utero, the fetus is contained in the sterile fluid-filled amniotic sac. If the membranes that compose the external lining of the amniotic sac rupture before term (before 37 weeks of gestation) or before the onset of normal labor at term, the fetal environment is no longer sterile, increasing the risk of fetal infection.

REF: p. 25 a. Cervical insufficiency b. Premature rupture of the fetal membranes c. Obstetrical intervention mandated by fetal jeopardy d. Hormonal treatment during pregnancy

9. Which of the following conditions is responsible for up to 40% of the preterm births in the United States?

ANS: B

The causes of premature rupture of the fetal membranes are generally not known but are responsible for 35 percent to 40 percent of preterm births in the United States. Preterm rupture of the fetal membranes can be seen as being responsible for all of the problems faced by most prematurely born infants.

REF: p. 25 a. Polyhydramnios b. Multihydramnios c. Oligohydramnios d. Anhydramnios

10. How should the therapist interpret an amniotic fluid index of 5 cm?

ANS: C

The amniotic fluid index (AFI) is calculated by measuring the largest vertical pockets of fluid in each of the four uterine quadrants at the time of ultrasound examination. Oligohydramnios, too little amniotic fluid or an AFI below 5 cm, is usually associated with congenital anomalies (especially renal agenesis or urinary tract obstruction), fetal growth restriction or demise, postterm pregnancy, ruptured membranes, uteroplacental insufficiency, and use of prostaglandin synthase inhibitors.

REF: p. 25 a. Magnesium sulfate b. Sodium bicarbonate c. Calcium carbonate d. Epinephrine

11. Once preterm labor is diagnosed, which of the following medications should be considered as tocolytic?

ANS: A

Once preterm labor is diagnosed, prompt measures should be taken to try to stop labor and prevent an early delivery. Intravenous hydration is commonly the first approach used. However, it does not seem to be of clinical significance in a well-hydrated patient. Excessive hydration should be avoided because it might exacerbate the risk of pulmonary edema that is usually associated with use of tocolytics. The most commonly used tocolytics are magnesium sulfate, beta-mimetic agents, and indomethacin (a prostaglandin inhibitor). Less commonly used are nifedipine (calcium channel blocker), nitroglycerin (nitric oxide donor drug), atosiban (oxytocin antagonist), and combination therapy.

REF: p. 27

12. A pregnant woman at 30 weeks of gestation with premature rupture of membranes has been admitted to the hospital with preterm labor. The physician has ordered betamethasone. When does the maximal benefit of antenatal corticosteroid occur to reduce RDS? a. After 12 hours b. After 24 hours c. After 48 hours d. After 1 week

ANS: C

All women between 24 and 34 weeks of gestation with preterm labor and intact membranes are candidates for antenatal corticosteroid therapy. Patients with preterm labor and ruptured membranes benefit from corticosteroid therapy between 24 and 32 weeks of gestation. Betamethasone and dexamethasone are most commonly used for antenatal corticosteroid therapy. Maximal benefit occurs 48 hours after initiation of therapy and lasts for 7 days.

REF: p. 27

13. Which of the following conditions is a significant problem in postterm pregnancy? a. Infection b. Fetal anencephaly c. Meconium aspiration d. Obesity

ANS: C

Meconium aspiration is a significant problem. Meconium passage in utero is common after 42 weeks of gestation. It is frequently associated with fetal hypoxia. Meconium becomes more concentrated in the amniotic fluid when associated with oligohydramnios. Aspiration of meconium may lead to obstruction of the respiratory passages and interference with surfactant function.

REF: p. 28

14. A woman 41-weeks pregnant is at high risk for complication in the postpartum period. Which of the following agents will be more appropriate to induce labor? a. Magnesium sulfate b. Aspirin c. Terbutaline d. Oxytocin

ANS: D

Labor induction can be achieved with various medications when the cervix is favorable for induction. Intravenous infusion of oxytocin, a hormone secreted from the posterior pituitary that stimulates uterine contractions and milk letdown, is most commonly used.

REF: p. 29 a. Amniocentesis b. Scalp fetal pH c. Stress test d. Needle ultrasound

15. What is the most common invasive procedure to assess the fetal condition?

ANS: A

The most commonly performed invasive procedure to assess fetal condition is amniocentesis. In this procedure, under sterile conditions a needle is inserted through the skin and uterine wall to obtain a sample of fluid from the amniotic sac (see Figure 3-3 in the textbook). Depending on the reason for performing the procedure, the concentration of many substances in the fluid can be measured. For example, as the fetal lung matures, pulmonary surfactant is secreted from the fetal lung into the amniotic fluid, where its concentration can be measured. Fetal cells isolated from amniotic fluid can be used to assess for fetal chromosomal abnormalities (e.g., trisomy 21), fetal enzyme deficiencies (e.g., Tay-Sachs), and certain discrete genetic mutations (e.g., sickle cell disease).

REF: p. 29 a. A C-section should be scheduled as soon as possible. b. No action is required because this reactive NST is associated with normal uteroplacental function. c. A CST should be performed before fetal stress is confirmed. d. Oxytocin should be to be administered to prevent more fetal stress.

16. The respiratory therapist is called to assist in the labor of a pregnant woman whose NST reported two accelerations in fetal heart rate, each of at least 15 beats per minute and lasting at least 15 seconds, associated with maternal perception of fetal movement over a period of 20 minutes. What is the best course of action?

ANS: B

A reactive NST requires at least two accelerations in fetal heart rate, each of at least 15 beats per minute and lasting at least 15 seconds, associated with maternal perception of fetal movement over a period of 20 minutes. A reactive NST is highly correlated with normal uteroplacental function.

REF: p. 30 a. Placenta abruption b. Oligohydramnios c. Uteroplacental insufficiency d. Nuchal cords

17. A fetus is undergoing a contraction stress test. Uterine contractions are stimulated by the intravenous infusion of oxytocin into the mother. The fetal PO2 drops below 12 mm Hg and causes the fetal heart rate to slow. Which of the following conditions is likely indicated by this occurrence?

ANS: C

During a contraction stress test FHR levels are monitored continuously while uterine contractions are stimulated by intravenous infusion into the mother of a dilute solution of oxytocin. In a normal pregnancy, fetal Po2 (partial pressure of oxygen) decreases with each uterine contraction and then rapidly returns to normal. A fetal Po2 drop below 12 mm Hg, resulting in slowing of the FHR, indicates uteroplacental insufficiency. This slowing of the FHR in response to uterine contractions is called a late deceleration.

REF: p. 30 a. The fetus requires careful evaluation and possibly immediate delivery. b. The fetus requires another biophysical profile in 24 hours. c. The fetus appears to be normal. d. The data are inconclusive and the profile needs to be redone immediately.

18. How should the therapist interpret a fetal biophysical profile score of 7?

ANS: C

The fetal biophysical profile (BPP) assesses placental function and fetal well-being. The BPP has been likened to the Apgar score. Five determinants of fetal status are assessed and a score of 0 to 2 given. Four are assessed by ultrasonography: fetal breathing, fetal tone, fetal gross body movement, and amniotic fluid volume. The fifth determinant is the nonstress test. A BPP score of 8 to 10 is considered normal and reassuring; a score of 6 is equivocal and is generally repeated within 24 hours; BPP scores of 0 to 4 are clearly abnormal and are associated with poor perinatal outcomes and require careful evaluation and usually immediate delivery.

REF: p. 30 a. Intraoperative bladder or bowel injuries b. Endomyometriosis c. Failure to progress in labor d. Placenta previa

19. Which of the following maternal complications is associated with cesarean section?

ANS: A

Although cesarean delivery might be the least traumatic for the fetus, for the mother it is associated with an increased risk of significant blood loss, anesthesia complications, intraoperative bladder or bowel injuries, postoperative wound infection, endomyometritis, and thromboembolic events. The syndrome of transient tachypnea of the newborn (wet lung or type II respiratory distress syndrome) includes the clinical features of cyanosis, grunting, and tachypnea during the first hours of life. It is more commonly seen in infants delivered by cesarean section. Placenta previa occurs when the placenta covers the cervical os. Cesarean delivery is usually required.

REF: p. 32 a. Fetal scalp stimulation b. Umbilical cord blood sampling c. Placental blood sampling d. Biophysical profile

20. In lieu of obtaining a scalp blood gas sample, what can the therapist do to conduct intrapartum assessment of the fetus?

ANS: A

On many obstetric services, when persistent severe variable or late decelerations of the FHR are diagnosed, fetal scalp blood is obtained via transvaginal fetal scalp puncture, allowing blood gas measurements to be obtained. Scalp blood pH greater than 7.25 is considered reassuring; values of 7.15 or less signal high risk of fetal acidemia. Many clinicians believe that scalp blood gas assessment in the face of an abnormal FHR pattern more precisely defines the fetus at risk and can thus prevent unnecessary forceps and cesarean deliveries. An alternative to scalp blood gas assessment is fetal scalp stimulation. Using the underlying rationale of the NST, transvaginal stimulation of the fetal scalp to induce fetal movement causes the fetal heart rate to accelerate and reassures the clinician that the fetus is not hypoxemic or acidemic.

REF: p. 32

21. A therapist is called to the labor and delivery room to assist in the resuscitation of a term newborn. If necessary, what FiO2 should be used to start positive pressure ventilation? a. 100% and wean as needed b. 21% and make changes utilizing preductal oximetry c. 50% and wean for SpO2 > 88% d. Any FiO2 as long as peak pressures do not exceed 20 cm H2O

ANS: B

One of the biggest changes to accepted resuscitation standards for newborns in NRP 2011 (6th ed) is the need for compressed air and pulse oximetry for all newborns requiring resuscitation. If ventilation is necessary, term infant ventilation is started with room air (21%) via positive pressure device, and changes in oxygen concentration are made utilizing clinical assessment and preductal pulse oximetry.

REF: pp. 34-35

22. A therapist treating a newborn with hypoxemia due to hypothermia should also be aware of which of the following conditions? a. Hypercarbia b. Hypoglycemia c. Hypocalcemia d. Left-to-right shunt

ANS: B

Thermal management is critically important to a successful extrauterine transition. Efforts should be made to reduce heat loss as much as possible. There is a marked increase in glucose and oxygen consumption when a newborn infant is cold stressed. In an infant with a difficult transition, cold stress may precipitate the development of persistent pulmonary hypertension, a clinical situation where pulmonary vascular resistance remains high, fetal shunts remain open, and blood flow to the newborn lung is minimal.

REF: p. 35 a. 20 to 30 breaths per minute b. 30 to 40 breaths per minute c. 40 to 60 breaths per minute d. 60 to 100 breaths per minute

23. A therapist is resuscitating a term newborn. What should be the rate of ventilation?

ANS: C

The rate of ventilation recommended is 40 to 60 breaths per minute and is determined by how frequently the bag is squeezed in the case of the self-inflating and flow-inflating bags.

REF: p. 35 a. Intubate and provide positive airway pressure b. Administer IV or ET epinephrine c. Apply bag-mask ventilation d. Continue compressions until heart rate is greater than 60

24. A therapist is resuscitating a term newborn. The heart rate falls to 55 beats per minute. What is the best course of action?

ANS: B

Medications should be prepared for administration if the heart rate remains below 60 beats per minute. Placing an umbilical catheter for administration is ideal for epinephrine administration. However, the first dose of epinephrine may be given via the ET tube if the placement of the umbilical line delays prompt administration of the medication. Doses of epinephrine will vary based on the route of administration.

REF: p. 35