Chapter 16 Assessment of Fetal Well-Being
1) A standard ultrasound examination is performed during the second or third
trimester and includes an evaluation of which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Confirm fetal heart activity.
2. Evaluate the cervix.
3. Determine fetal presentation.
4. Amniotic fluid volume.
5. Fetal number.
Answer: 3, 4, 5
Explanation: 3. A standard ultrasound examination is performed during the
second or third trimester and includes an evaluation to determine fetal
presentation.
4. A standard ultrasound examination is performed during the second or third
trimester and includes an evaluation of amniotic fluid volume.
5. A standard ultrasound examination is performed during the second or third
trimester and includes an evaluation of fetal number.
Page Ref: 414
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences,
and expressed needs as part of clinical interview, implementation of care
plan, and evaluation of care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Context and Environment: Read and
interpret data; apply health promotion/disease prevention strategies; apply
health policy; conduct population-based transcultural health assessments and
,interventions. | Nursing/Integrated Concepts: Nursing Process:
Implementation
Learning Outcome: 4 Delineate the use of ultrasound in the second trimester
to assess fetal life, number, presentation, anatomy, age, and growth.
MNL LO: 2.8.3 Examine indications and procedures for antenatal testing
performed during the second trimester.
1
Copyright 2016 Pearson Education, Inc.
2) When assisting with a transabdominal sampling, which of the following
would the nurse do?
1. Obtain preliminary urinary samples.
2. Have the woman empty her bladder before the test begins.
3. Assist the woman into a supine position on the examining table.
4. Instruct the woman to eat a fat-free meal 2 hours before the scheduled test
time.
Answer: 3
,Explanation: 3. Clients are placed in a supine position on the table.
Page Ref: 436
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences,
and expressed needs as part of clinical interview, implementation of care
plan, and evaluation of care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Context and Environment: Read and
interpret data; apply health promotion/disease prevention strategies; apply
health policy; conduct population-based transcultural health assessments and
interventions. | Nursing/Integrated Concepts: Nursing Process:
Implementation
Learning Outcome: 2 Identify indications and interpret findings for
ultrasound examinations performed in the first trimester.
MNL LO: 2.8.1 Explain the nurses role and responsibilities in the
administration of antenatal testing.
3) The nurse is preparing a client in her second trimester for a three-
dimensional ultrasound examination. Which statement indicates that teaching
has been effective?
1. If the ultrasound is normal, it means my baby has no abnormalities.
2. The nuchal translucency measurement will diagnose Down syndrome.
3. I might be able to see who the baby looks like with the ultrasound.
4. Measuring the length of my cervix will determine whether I will deliver
early.
Answer: 3
Explanation: 3. Three-dimensional ultrasound uses algorithms to vary
opacity, transparency, and depth to project an image. This allows curved
structures such as the fetal face to be viewed.
Page Ref: 413
, Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with
sensitivity and respect for the diversity of human experience. | AACN
Essentials Competencies: IX. 3. Implement holistic, patient-centered care that
reflects an understanding of human growth and development, pathophysiology,
pharmacology, medical management, and nursing management across the
health-illness continuum, across lifespan, and in all health care settings. | NLN
Competencies: Relationship-Centered Care: Communicate information
effectively; listen openly and cooperatively. | Nursing/Integrated Concepts:
Nursing Process: Evaluation
Learning Outcome: 4 Delineate the use of ultrasound in the second trimester
to assess fetal life, number, presentation, anatomy, age, and growth.
2
Copyright 2016 Pearson Education, Inc.
MNL LO: 2.8.1 Explain the nurses role and responsibilities in the
administration of antenatal testing.
4) A woman at 28 weeks gestation is asked to keep a fetal activity record and
to bring the results with her to her next clinic visit. One week later, she calls
the clinic and anxiously tells the nurse that she has not felt the baby move for
more than 30 minutes. Which of the following would be the nurses most
appropriate initial comment?
1. You need to come to the clinic right away for further evaluation.
2. Have you been smoking?
3. When did you eat last?
4. Your baby might be asleep.
Answer: 4
Explanation: 4. Lack of fetal activity for 30 minutes typically is insignificant.
Movement varies considerably, but most women feel fetal movement at least
10 times in 3 hours.
Page Ref: 424
1) A standard ultrasound examination is performed during the second or third
trimester and includes an evaluation of which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Confirm fetal heart activity.
2. Evaluate the cervix.
3. Determine fetal presentation.
4. Amniotic fluid volume.
5. Fetal number.
Answer: 3, 4, 5
Explanation: 3. A standard ultrasound examination is performed during the
second or third trimester and includes an evaluation to determine fetal
presentation.
4. A standard ultrasound examination is performed during the second or third
trimester and includes an evaluation of amniotic fluid volume.
5. A standard ultrasound examination is performed during the second or third
trimester and includes an evaluation of fetal number.
Page Ref: 414
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences,
and expressed needs as part of clinical interview, implementation of care
plan, and evaluation of care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Context and Environment: Read and
interpret data; apply health promotion/disease prevention strategies; apply
health policy; conduct population-based transcultural health assessments and
,interventions. | Nursing/Integrated Concepts: Nursing Process:
Implementation
Learning Outcome: 4 Delineate the use of ultrasound in the second trimester
to assess fetal life, number, presentation, anatomy, age, and growth.
MNL LO: 2.8.3 Examine indications and procedures for antenatal testing
performed during the second trimester.
1
Copyright 2016 Pearson Education, Inc.
2) When assisting with a transabdominal sampling, which of the following
would the nurse do?
1. Obtain preliminary urinary samples.
2. Have the woman empty her bladder before the test begins.
3. Assist the woman into a supine position on the examining table.
4. Instruct the woman to eat a fat-free meal 2 hours before the scheduled test
time.
Answer: 3
,Explanation: 3. Clients are placed in a supine position on the table.
Page Ref: 436
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences,
and expressed needs as part of clinical interview, implementation of care
plan, and evaluation of care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Context and Environment: Read and
interpret data; apply health promotion/disease prevention strategies; apply
health policy; conduct population-based transcultural health assessments and
interventions. | Nursing/Integrated Concepts: Nursing Process:
Implementation
Learning Outcome: 2 Identify indications and interpret findings for
ultrasound examinations performed in the first trimester.
MNL LO: 2.8.1 Explain the nurses role and responsibilities in the
administration of antenatal testing.
3) The nurse is preparing a client in her second trimester for a three-
dimensional ultrasound examination. Which statement indicates that teaching
has been effective?
1. If the ultrasound is normal, it means my baby has no abnormalities.
2. The nuchal translucency measurement will diagnose Down syndrome.
3. I might be able to see who the baby looks like with the ultrasound.
4. Measuring the length of my cervix will determine whether I will deliver
early.
Answer: 3
Explanation: 3. Three-dimensional ultrasound uses algorithms to vary
opacity, transparency, and depth to project an image. This allows curved
structures such as the fetal face to be viewed.
Page Ref: 413
, Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with
sensitivity and respect for the diversity of human experience. | AACN
Essentials Competencies: IX. 3. Implement holistic, patient-centered care that
reflects an understanding of human growth and development, pathophysiology,
pharmacology, medical management, and nursing management across the
health-illness continuum, across lifespan, and in all health care settings. | NLN
Competencies: Relationship-Centered Care: Communicate information
effectively; listen openly and cooperatively. | Nursing/Integrated Concepts:
Nursing Process: Evaluation
Learning Outcome: 4 Delineate the use of ultrasound in the second trimester
to assess fetal life, number, presentation, anatomy, age, and growth.
2
Copyright 2016 Pearson Education, Inc.
MNL LO: 2.8.1 Explain the nurses role and responsibilities in the
administration of antenatal testing.
4) A woman at 28 weeks gestation is asked to keep a fetal activity record and
to bring the results with her to her next clinic visit. One week later, she calls
the clinic and anxiously tells the nurse that she has not felt the baby move for
more than 30 minutes. Which of the following would be the nurses most
appropriate initial comment?
1. You need to come to the clinic right away for further evaluation.
2. Have you been smoking?
3. When did you eat last?
4. Your baby might be asleep.
Answer: 4
Explanation: 4. Lack of fetal activity for 30 minutes typically is insignificant.
Movement varies considerably, but most women feel fetal movement at least
10 times in 3 hours.
Page Ref: 424
