Which assessments are included in the fetal biophysical profile (BPP)? (Select all that apply.)
AFI
Fetal heart rate
Fetal movement
Fetal tone
Placental grade
Correct Answer : A,B,C,D
Choice A reason: AFI stands for amniotic fluid index, which is a measurement of the amount of amniotic fluid surrounding the fetus. AFI is an indicator of fetal well-being, as it reflects the fetal urine output and the placental function. A normal AFI is between 5 and 25 cm. A low AFI (< 5 cm) can suggest fetal growth restriction, oligohydramnios, or fetal distress. A high AFI (> 25 cm) can suggest fetal anomalies, polyhydramnios, or maternal diabetes.
Choice B reason: Fetal heart rate is an assessment of the fetal cardiac activity, which is usually monitored by a non-stress test (NST). Fetal heart rate is an indicator of fetal well-being, as it reflects the fetal oxygenation and the autonomic nervous system. A normal fetal heart rate is between 110 and 160 beats per minute, with moderate variability and accelerations. A non-reactive fetal heart rate (< 2 accelerations in 20 minutes) can suggest fetal hypoxia, acidosis, or distress.
Choice C reason: Fetal movement is an assessment of the fetal gross body movements, which are usually counted by the mother or observed by ultrasound. Fetal movement is an indicator of fetal well-being, as it reflects the fetal activity and the central nervous system. A normal fetal movement is at least 3 movements in 30 minutes. A decreased fetal movement (< 3 movements in 2 hours) can suggest fetal sleep, sedation, or distress.
Choice D reason: Fetal tone is an assessment of the fetal muscle tone, which is usually observed by ultrasound. Fetal tone is an indicator of fetal well-being, as it reflects the fetal maturity and the neuromuscular system. A normal fetal tone is at least 1 episode of fetal flexion or extension in 30 minutes. An abnormal fetal tone (absent or hypotonic) can suggest fetal immaturity, anomalies, or distress.
Choice E reason: Placental grade is not an assessment that is included in the fetal biophysical profile (BPP), as it is not a direct measure of fetal well-being, but rather a classification of the placental maturity and calcification. Placental grade is usually evaluated by ultrasound, and it ranges from 0 to 3, with higher grades indicating more calcification and aging. Placental grade can affect the placental function and the fetal growth, but it is not a reliable or consistent indicator of fetal distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "I know I am at increased risk to develop type 2 diabetes." is a correct statement, because it indicates that the client understands the long-term implications of gestational diabetes. The client should be aware that gestational diabetes increases the risk of developing type 2 diabetes later in life, and that she should have regular screening and follow-up.
Choice B reason: "I will take my glyburide daily with breakfast." is a correct statement, because it indicates that the client understands the medication regimen for gestational diabetes. The client should take glyburide, a sulfonylurea that lowers blood glucose levels, as prescribed by the provider, and monitor her blood glucose levels before and after meals.
Choice C reason: "I will reduce my exercise schedule to 3 days a week." is an incorrect statement, because it indicates that the client does not understand the importance of physical activity for gestational diabetes. The client should exercise at least 30 minutes a day, 5 days a week, unless contraindicated by the provider. Exercise can help improve insulin sensitivity, lower blood glucose levels, and prevent excessive weight gain.
Choice D reason: "I should limit my carbohydrates to 50% of caloric intake." is a correct statement, because it indicates that the client understands the dietary guidelines for gestational diabetes. The client should consume a balanced diet that provides adequate but not excessive amounts of carbohydrates, protein, and fat, and that is consistent in carbohydrate intake throughout the day.
Correct Answer is C
Explanation
Choice A reason: Monitoring the newborn's blood pressure is not the most appropriate action, as it is not directly related to the signs of diaphoresis, jitteriness, and lethargy. These signs are more indicative of hypoglycemia, which is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers.
Choice B reason: Initiating phototherapy is not the most appropriate action, as it is used to treat hyperbilirubinemia, which is a high level of bilirubin in the blood that can cause jaundice, a yellowish discoloration of the skin and eyes. Hyperbilirubinemia does not cause diaphoresis, jitteriness, or lethargy.
Choice C reason: Obtaining blood glucose by heel stick is the most appropriate action, as it can confirm the diagnosis of hypoglycemia, which is the most likely cause of the signs of diaphoresis, jitteriness, and lethargy. The nurse should perform a heel stick using a sterile lancet and a glucose meter, and obtain a blood sample from the lateral aspect of the heel. The nurse should also provide warmth, stimulation, and feeding to the newborn, and report the blood glucose level to the provider.
Choice D reason: Placing the newborn in a radiant warmer is not the most appropriate action, as it can cause dehydration, fluid loss, and further hypoglycemia. The nurse should use a radiant warmer only if the newborn is hypothermic, which is a low body temperature that can also affect newborns. The nurse should monitor the newborn's temperature and skin color, and adjust the warmer accordingly.
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