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: A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions does not need to be reported to the provider immediately, because it may indicate preterm labor, which is not an emergency. The nurse should assess the client's cervix, fetal heart rate, and hydration status, and administer tocolytic therapy as prescribed.
Choice B reason: A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes does not need to be reported to the provider immediately, because they are expected findings in mild preeclampsia. The nurse should monitor the client's blood pressure, urine output, and reflexes, and administer antihypertensive and anticonvulsant medications as prescribed.
Choice C reason: A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache needs to be reported to the provider immediately, because they are signs of severe preeclampsia or impending eclampsia. The nurse should prepare the client for delivery, as it is the only definitive treatment for preeclampsia.
Choice D reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors does not need to be reported to the provider immediately, because they are a common and mild side effect of terbutaline, a beta-adrenergic agonist that relaxes the uterine smooth muscle. The nurse should reassure the client that the tremors are temporary and harmless, and monitor the client's pulse and blood pressure.
Correct Answer is C
Explanation
Choice A reason: To call for an immediate magnesium sulfate level is not the immediate action that the nurse should take, as it is a diagnostic test that requires a blood sample and a laboratory analysis, which can take time and delay the treatment. The nurse should first stop the infusion and notify the provider, as the client is showing signs of magnesium sulfate toxicity, which is a life-threatening condition that can cause respiratory depression, cardiac arrest, or coma.
Choice B reason: To prepare to administer hydralazine is not the immediate action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the blood pressure and the fetal status. Hydralazine is an antihypertensive drug that lowers the blood pressure and prevents the complications of severe preeclampsia, such as eclampsia, stroke, or organ damage. However, the client's blood pressure is not very high and is not the main problem at the moment.
Choice C reason: To discontinue the magnesium sulfate infusion is the immediate action that the nurse should take, as it is the first and most important intervention that can reverse the effects of magnesium sulfate and restore the neuromuscular function and the respiratory rate. Magnesium sulfate is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, but it can also cause toxicity if the dose is too high or the infusion is too fast.
Choice D reason: To administer oxygen is not the immediate action that the nurse should take, as it is a supportive intervention that improves the oxygen delivery to the tissues and organs, but does not address the underlying cause of the respiratory depression, which is the magnesium sulfate toxicity. The nurse should administer oxygen only after stopping the infusion and assessing the oxygen saturation and the respiratory status.
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