NCLEX-RN: Maternal–Newborn Nursing: Fetal Assessment

Maternal–Newborn Nursing: Fetal Assessment

Biochemical Measurements

A. Estriol excretion: Estrogen metabolism in pregnancy is dependent on a healthy mother, a healthy fetus, and an intact placenta.

  • Estriol level increases as the fetus grows and decreases when growth ceases.
  • Measured by 24-hour urine specimen or serum estriol levels.
  • Provides guide to normalcy of fetoplacental unit.

a. Placental functioning.
b. Fetal well-being.

  • Excretion of high estriol levels indicates good function; low levels may indicate fetal jeopardy.
  • Serial assays are usually done, starting at about 32 weeks, to assess the fetal condition.

B. Human placental lactogen (HPL).

  • Product of the placenta.
  • Increased levels during pregnancy correspond with increase in fetal weight.

Maternal–Newborn Nursing: Amniotic Fluid Studies

A. Amniocentesis is the introduction of a needle through the abdominal and uterine walls and into the amniotic cavity to withdraw fluid for examination.

  • Amniocentesis indicates

a. Sex of baby.
b. Certain congenital defects such as Down syndrome.
c. State of fetus affected by Rh isoimmunization.

  • Advanced maternal age—over 35, or suspected abnormality.
  • Test provides clearest chromosome profile, but is usually done after 14 weeks—may be done as early as 12 weeks.
  • Procedure.

a. Amniotic fluid obtained via transabdominal or suprapubic amniocentesis.

(1) Complications rare (less than 1%).
(2) Rh-negative women would receive Rh-immune globulin after amniocentesis, if not already sensitized.

b. Performed at about 16 weeks; takes 2 to 4 weeks for results.
c. Positive test indicates fetus has genetic disorder.
d. Preceded by ultrasound.

B. Amniotic fluid may be analyzed to determine maturity of fetal lungs.

Maternal–Newborn Nursing: Evaluation of Fetal Maturity

A. Lecithin/sphingomyelin ratio (L/S ratio).

1. Test for fetal maturity by examining the ratio of two components of surfactant––lecithin and sphingomyelin.

2. Lecithin major constituent of surfactant in the lungs.

3. At thirteen week, the concentration of sphingomyelin is higher than lecithin.

4. Thereafter, lecithin increases slowly until the thirty-five week, when it is two or more times greater than sphingomyelin. At this time, fetal lungs are said to be mature and can maintain stability with the first breath, and the infant is unlikely to develop respiratory distress syndrome (RDS).

B. Phosphatidylglycerol (PG).

1. Second most abundant phospholipid in surfactant.

a. Appears at 35 to 36 weeks and increases until term.
b. Presence of this lipid indicates low risk for RDS.

2. Recently, lung maturity is determined by combination of L/S ratio and PG.

Maternal–Newborn Nursing: Chorionic Villus Sampling


A. Diagnostic capability similar to amniocentesis; results reflect fetal chromosome, enzyme, and DNA content.

B. Advantage is that diagnostic information is available before end of first trimester of pregnancy.

C. Disadvantage––increased risk of pregnancy loss.


A. A transcervical or transabdominal approach used to aspirate chorionic villi from the chorion.

B. Syringe contents (villi) inspected microscopically and prepared for culture.

C. Results are available in 1–2 weeks.

Maternal–Newborn Nursing: Alpha-Fetoprotein

A. Principal screening procedure for detection of neural tube defect (spina bifida, hydrocephalus; incidence is 1 per 1000–2000 births in United States).

B. Levels of maternal serum alpha-fetoprotein (AFP) detect possible abnormalities in fetus.

C. Multipurpose test done at 16–18 weeks.

D. Mother’s blood is analyzed for amount of AFP that liver normally re releases at a known and increasing amount as pregnancy proceeds—follow up with ultrasound (US), amniocentesis, or CVS.

1. Low levels detect Down syndrome and maternal hypertensive states.
2. High levels detect open neural tube defects, risk of premature delivery, toxemia, fetal distress, Rh isoimmunization.

E. Procedure allows families to choose whether to have a child with an identified birth defect.

F. Incidence of neural tube defect can be reduced with use of folic acid (0.4 mg/day) prior to and during first trimester of pregnancy.

Maternal–Newborn Nursing: Ultrasound

A. A diagnostic test of intermittent high-frequency sound waves that reflect off tissues according to varying densities.

1. Most common diagnostic procedure––70% of pregnant women in United States.
2. Evaluates both functional and structural characteristics.

B. Advantages—technique is noninvasive, nondamaging, and painless.

C. Purpose—to differentiate tissue mass and do serial studies. Determines fetal movements, breathing, heart valve capability.

D. Results—detects placental location (for amniocentesis, placenta previa) gestational age, presence of twins, fetal growth, major malformations, amniotic fluid volume, and presence of pelvic masses.

E. Procedure—client instructed to have a full bladder; test takes 20–30 minutes to complete. Near term, anticipate supine hypotension, nausea, and vertigo.

Maternal–Newborn Nursing: Nonstress Test


A. Test designed to evaluate fetal status by measuring fetal baseline heart rate and variability. May also include record of fetal movement as reported by the client.

B. Indicated in conditions of known maternal problems such as diabetes, chronic hypertension (HTN), and preeclampsia.

C. Usually given after the thirtytwo week on a weekly or semiweekly schedule and on an outpatient basis. Procedure

A. Place client in semi-Fowler’s position—may use a recliner chair.

B. Take baseline vital signs.

C. Place external monitor over fundus of uterus.

D. Instruct client to press recording button each time she feels fetal movement.

E. Normal test time is 20–40 minutes.

F. Record fetal heart rate and contractile activity.

1. A reactive NST (two or more accelerations of 15 beats/min or more, lasting 15 seconds or more, within 20 minutes) shows a healthy fetus with good reserves—a monitor strip with a normal fetal heart rate, pattern, and good variability.
2. A nonreactive test does not meet the above criteria.

Maternal–Newborn Nursing: Contraction Stress Test


A. Test results determine status of fetoplacental unit—evaluates fetus’s ability to tolerate stress of uterine contraction.

1. If placental flow is normal, fetus remains oxygenated during uterine contractions.
2. Placental insufficiency produces characteristic late deceleration pattern during contraction. (Fetal bradycardia is less than 110 beats/min or persistent drop of 20 beats below baseline.)

B. Three consecutive contractions of at least 40 seconds in a 10-minute period—may take 1–2 hours.

1. A positive CST reaction would be persistent late decelerations or bradycardia.
2. If fetus cannot withstand mild contractions, cesarean delivery is indicated.

C. Following test, observe for complications.

1. Fetal heart rate below 110.
2. Sustained uterine contractions.
3. Supine hypotensive syndrome (check maternal blood pressure).


A. Client usually not admitted.

B. Place client in semi-Fowler’s or lateral recumbent position to prevent supine hypotensive syndrome.

C. Give liquid nourishment if ordered.

D. Explain procedure to client.

E. Apply external fetal monitor.

F. Observe for uterine activity and fetal heart rate usually for 10–20 minutes to obtain baseline.

G. Intravenous (IV) solution with oxytocic drug is started; infusion pump used to administer more accurate dosage.

H. Dosage is increased every 15–20 minutes until client has three good contractions in a 10-minute period. (Pitocin [oxytocin] is discontinued once pattern is established.)

I. Observe client for signs of sensitivity to drug.

J. Record vital signs and oxytocic infusion every 15 minutes on strip.

K. Monitor contractions and fetal heart rate until client returns to preoxytocic state.

L. Discontinue IV and prepare client for discharge.

M. Record all information on chart; monitor strip is considered legal document and becomes part of chart.

N. Discontinue drug immediately if fetal heart rate decreases to below 110 or sustained uterine contraction develops.

Maternal–Newborn Nursing: Mammary Stimulation Test

A. Also called breast self-stimulation test (BSST). Purpose— start contractions without the use of oxytocin.

B. Preferred method—noninvasive.

C. Procedure—manual stimulation of mother’s nipples triggers release of oxytocin to induce contractions (follow CST except roll nipples for 5 minutes, then other side if no contractions).

1. Contractions similar to those with spontaneous labor.
2. Nerve impulses cause release of endogenous oxytocin.
3. When three contractions occur in 10 minutes, breast stimulation is stopped.
4. Assess fetal heart rate for prolonged decelerations.
5. Perform test in or near delivery room.

Maternal–Newborn Nursing: Biophysical Profile or Score

A. Profile identifies fetus in danger and confirms a healthy fetus.

B. A score of 2 for each normal finding and 0 for each abnormal finding for a maximum of 10.

C. Assessment of five parameters by ultrasound for 30 minutes.

1. Fetal muscle tone.
2. Fetal movements—body or limbs (three per hour).
3. Breathing movements.
4. Amniotic fluid volume.
5. FHR reactivity (assessed with nonstress test).

D. Results of scoring.

1. Scores of 8–10 reassuring, but repeat testing is indicated.
2. Scores of 5–6 equivocal, and repeat testing should be done within 24 hours.
3. Scores of 4 or less worrisome and indicate immediate delivery is necessary.

Maternal–Newborn Nursing: Complications of Pregnancy

Definition: High-risk pregnancy occurs when there is an increased chance of morbidity and/or mortality to the mother and/or fetus due to the presence of a complicating factor.


A. The development of obstetrically related conditions during the pregnancy such as vaginal bleeding, toxic states, and premature labor.

B. Medical conditions such as cardiac disease, diabetes, or infection.

C. Unfavorable obstetrical history such as high parity— five or more pregnancies, previous infant death, premature birth, or infant with congenital malformations, difficulty in conceiving, less than a year since last pregnancy, and Rh incompatibility.

D. Psychosocial conditions such as under 17 years of age, narcotic or alcohol addiction, and poverty.


A. Obtain a general assessment of pregnant client for signs indicative of the development of complications. Include an accurate health history.

B. Observe for presence of danger signals.

1. Bleeding from the vagina.
2. Escape of amniotic fluid denoting premature rupture of the membranes.
3. Contractions increasing in strength, duration, and proximity before term.
4. Dizziness or blurred vision or epigastric pain.
5. Edema of the face and fingers.
6. Persistent and severe vomiting.
7. Chills, malaise, and/or elevated temperature.
8. Absence of or significant and consistent decrease in fetal movement.
9. Decrease or absence of fetal heart tones.


A. Assess, monitor, and control the specific conditions leading to identification of the client as high risk.

B. Refer to following conditions for specific management.

Maternal–Newborn Nursing: Spontaneous Abortion


A. Spontaneous abortion is defined as the involuntary expulsion of the fetus before viability.

B. Threatened: some loss of blood and pain without loss of products of conception.

C. Imminent: profuse bleeding, severe contractions, bearing-down sensation; without intervention, products of conception will be lost.

D. Inevitable: bleeding, contractions, ruptured membranes, and cervical dilation.

E. Incomplete: portion of products of conception remain in uterine cavity.

F. Complete: all products of conception expelled.

G. Missed: fetus dies, but is retained for 4 weeks or more.

H. Septic: products of conception become infected.

I. Recurrent: abortion in three or more succeeding pregnancies.


A. Abnormalities of fetus; blighted embryo.

B. Abnormalities of reproductive tract.

C. Injuries: physical and emotional shocks.

D. Endocrine disturbances.

E. Acute infectious diseases.

F. Maternal diseases.

G. Psychogenic problems.


A. Observe amount of vaginal bleeding: slight, moderate, or heavy.


Maternal–Newborn Nursing


B. Evaluate intermittent contractions, pain (usually beginning in the small of the back), and abdominal cramping.

C. Observe for passage of tissue.

D. Evaluate condition of internal cervical os.

E. Evaluate size of uterus and compare estimated length of pregnancy.

F. Assess psychological state of client.


A. Save all perineal pads and expelled tissue for examination.

B. Offer emotional support but do not give false reassurance.

C. Observe for signs of shock and institute emergency measures if necessary (type and crossmatch).

D. Maintain client on bed rest.

E. Provide instructions regarding activity restriction.

F. Provide diversional activities while on bed rest.

G. If incompetent cervix is treated with cerclage, provide the following nursing care:

1. Place woman in Trendelenburg’s position to keep pressure off cervix.
2. Continuously monitor fetal heart tone and contractions.
3. Observe for premature rupture of the membranes.
4. When woman goes into labor, verify that all sutures are removed and carefully observe labor pattern.

H. Ensure that client receives counseling psychotherapy if needed.

I. Have client restrict activities such as climbing stairs and coitus for at least 2 weeks after bleeding stops.

Maternal–Newborn Nursing: Extrauterine or Ectopic Pregnancy

Definition: Implantation of the fertilized ovum outside the uterus; usually cannot develop longer than 10 to 12 weeks.


A. Although the fertilized ovum usually attaches to the uterine lining, it may become implanted at any point between the graafian follicle and the uterus.

B. Tubal pregnancy is the most common form (97%), but the ovum may attach to an ovary, the cervix, the abdomen, or interligaments.

C. Implantation.

1. Ovum attaches to tube and erodes into mucosa wall, as it would to the endometrial lining of the uterus.
2. Tube increases in size and stretches.
3. Pregnancy usually terminates during the first
3 months by:

a. Spontaneous tubal abortion.
b. Tubal rupture.
c. Death and disintegration of products of conception within the tube.

D. Abdominal pregnancies have been known to progress to term.

E. Etiology.

1. Progress of ovum through tube is delayed for some reason.
2. Hormonal factors and behavioral factors—smoking.
3. Tubal deformities: congenital or due to disease such as gonorrhea or chlamydia.
4. Tumors pressing against the tube.
5. Adhesions from previous surgery.
6. Tubal spasms.
7. Migration of ovum to opposite tube.


A. History of missed periods and “spotting.”

B. Early signs of pregnancy. (Woman may or may not know she is pregnant.)

C. Anemia—fatigue and pale mucous membranes.

D. Enlarged uterus due to hormonal influence.

E. Slight abdominal pain or sudden excruciating onesided lower abdominal pain.

1. Often first indication of ruptured tube.
2. Fifty percent experience referred right shoulder pain.

F. Fainting and lightheadedness (occurs in 35% to 50%).

G. Laboratory tests and ultrasound. Implementation

A. Institute same care as for postsurgical client.

B. Observe for signs of shock and institute treatment for shock as necessary.

C. Protect client against undue fatigue and infection (energy level and resistance will be low because of severe blood loss).

D. Provide emotional support: client may be frightened and feel the loss of the pregnancy.

Maternal–Newborn Nursing: Hydatidiform Mole

Definition: A benign neoplasm of the chorion, in which chorionic villi degenerate, become filled with a clear viscous fluid, and assume the appearance of grapelike clusters involving all or parts of the decidual lining of the uterus. Also called trophoblastic disease.


A. Classified in two ways: complete mole (contains no genetic maternal material) and partial mole (contains 69 chromosomes––normal is 46).

B. Incidence is rare—occurs once in every 1000–1500 pregnancies, except in Asia where it is more common.

C. Usually there is no fetus found—may be pathological ova.

D. High incidence (1 in 250) in Asia may be due to dietary protein deficiency.


A. Evaluate for vaginal bleeding: may vary from spotting to profuse; anemia as result of blood loss.

B. Assess for intermittent brownish discharge after the 12th week.

C. Check for enlargement of the uterus; may be out of proportion to duration of pregnancy.

D. Check for nausea and vomiting: appears earlier, is more severe, and lasts longer than normal.

E. Evaluate for severe preeclampsia, which develops in the early part of the second trimester.

F. Evaluate for pregnancy-induced hypertension (PIH), which occurs with the rapid expansion of the uterus.

G. Assess for passage of characteristic vesicles.

H. Check fetal heart tones: none may be heard; no fetal parts may be discerned.


A. Observe for uterine hemorrhage following evacuation because the uterus is very fragile and has little tone.


Maternal–Newborn Nursing


B. Provide emotional support: client may fear a malignancy or may feel the loss of the baby or repulsion at products of conception.

C. Encourage client to have follow-up treatment because of possibility of development of neoplasm.

D. Have client avoid pregnancy for 1 year from negative test because pregnancy may mask increasing levels of hCG due to development of choriocarcinoma.

Maternal–Newborn Nursing: Amniotic Fluid Abnormalities

Definition: A minimal or excessive amount of amniotic fluid. Normal amount is 500–1000 mL. The volume in the uterus is an indicator of fetal well-being and placental function.

A. Amount of amniotic fluid can be evaluated by amniotic fluid volume (AFV) or index (AFI).

1. Ultrasound (for AFV) measures pockets of fluid in uterus and calculates normal amount in centimeters.

a. Pocket measure at least 2–8 cm across is normal.
b. Greater than 8 cm is associated with polyhydramnios.
c. Less than 2 cm is associated with oligohydramnios.

2. AFI measures pockets of amniotic fluid in four quadrants of uterus.

a. AFI greater than 20 cm (combining amount in all four quadrants) indicates hydramnios.
b. AFI less than 5 cm indicates oligohydramnios.

B. Hydramnios (polyhydramnios).

1. Actual cause is unknown. Occurs when there is over 2000 mL of amniotic fluid.
2. Occurs with major fetal malformations(Down syndrome, congenital heart defects, craniospinal malformation, and orogastrointestinal anomalies).
3. Diagnosis is usually made through clinical observation of the greatly enlarged uterus.
4. Assessment.

a. Observe for greatly enlarged abdomen.
b. Evaluate edema of the lower extremities.
c. Question if general abdominal discomfort is present.
d. Observe for occasional shortness of breath.
e. Assess for presence of diabetes and Rhsensitization as this condition frequently accompanies it.

5. Implementation.

a. Instruct client to empty bladder so it will not distend.
b. Monitor vital signs.
c. Place client in semi-Fowler’s position to assist in breathing if not contraindicated.

C. Oligohydramnios.

1. Minimal amniotic fluid—less than 500 mL.
2. Indicates possible fetal compromise—congenital anomalies of renal aplasia and kidney defects, postmaturity, pulmonary hypoplasia, and placental insufficiency.
3. Assessment.

a. Uterus does not increase in size corresponding to age of fetus.
b. Fetus is easily palpated.

4. Implementation.

a. Acute oligohydramnios, rapid infusion of 100 mL lactated Ringer’s solution may be given to client to increase blood volume.
b. Plan for cesarean delivery because with low fluid, fetus may not be able to tolerate pressure of labor.
c. Continual electronic fetal monitoring (EFM):

(1) Assess for nonreassuring signs (baseline changes, decreased variability, periodic decelerations from cord compression or placental insufficiency).
(2) Change positions and/or start amnioinfusion to relieve deceleration pattern.

d. Fetus is examined immediately for any congenital problem.

Maternal–Newborn Nursing: Placenta Previa

Definition: A condition in which the ovum implants low in the uterus, toward the cervix, and the placenta develops so that it partially or completely covers the internal os. Occurs once in every 200 pregnancies.


A. Types.

1. Complete: internal os entirely covered.
2. Partial: only part of internal os covered.
3. Marginal: margin overlaps os (lies within 2–3 cm of internal os).

B. Occurs more often in multiparas.

C. Occurs more often with increased age of mother.

D. Scarring or tumor of uterus.


A. Observe for painless, bright red vaginal bleeding, intermittent or in gushes, after the seventh month without precipitating cause. (As internal os begins to dilate, the part of the uterus that overlies the os separates and leaves gaping vessels, so bleeding occurs.)


Maternal–Newborn Nursing


B. Evaluate uterine tone and contractibility.

C. Check for signs of hemorrhage.

D. Assess pain if any (generally painless).

E. Assess vital signs.


A. Maintain client in bed and provide quiet, restful atmosphere and diversion.

B. Count perineal pads and measure blood amounts on bedding, Chux, etc.

C. Give emotional support, explain procedures, and allay fears.

D. Do not perform vaginal examination.

E. Have emergency setup for cesarean delivery available.

F. Carefully monitor fetal heart tones with external monitor.

G. Monitor carefully postpartum for bleeding and infection.

Maternal–Newborn Nursing: Abruptio Placentae

Definition: A condition that occurs when the placenta separates from the normal implantation site in upper segment of uterus before birth of baby; occurs once in 90 pregnancies and accounts for 15% of perinatal mortality.


A. Types of separation.

1. Complete: Placenta becomes completely detached from uterine wall.

2. Partial: Portion of placenta becomes detached from uterine wall.

3. Central: Placenta separates centrally and blood is trapped between placenta and uterine wall; concealed bleeding.

Maternal–Newborn Nursing

B. Hemorrhage.

1. External (apparent): Blood escapes from the vagina.
2. Concealed: Blood is retained in uterine cavity.

C. Etiology.

1. Hypertensive disease (pregnancy-induced hypertension or chronic hypertension).
2. Previous abruption.
3. Trauma.
4. Smoking.
5. Cocaine use.


A. External assessment: Chief symptom is dark vaginal bleeding accompanied by abdominal pain.

B. Evaluate concealed condition.

1. Intense, cramplike uterine pain.
2. Uterine tenderness and rigidity.
3. Lack of alternate contraction—relaxation of uterus.
4. Fetal heart tones—bradycardia or absent.

C. Assess for early and late signs of shock: restlessness, narrowing pulse pressure, hypotension, increased pulse rate, pallor, changes in levels of consciousness (LOC).

D. Continuous evaluation for disseminated intravascular coagulation (DIC).


A. Keep client on bed rest.

B. Observe for signs of shock.

C. Carefully monitor contractions (electronic monitor), fetal heart rate, and vital signs.

D. If bleeding is severe, begin administration of intravenous solution: Ringer’s lactate at 150 mL/hr.

E. Order type and crossmatch blood for possible transfusion, and blood tests for platelets, fibrinogenlevel, prothrombin time (PT), partial thromboplastin time (PTT).

F. Monitor central venous pressure (CVP).

G. Record intake and output (I&O) and observe for anuria or oliguria. (Anuria may develop as a result of decreased kidney perfusion.)

H. Provide emotional support as fetal prognosis is guarded.

I. Observe for hemorrhage after delivery.

J. Observe for DIC (client at risk for uterine atony after birth).

Maternal–Newborn Nursing: Hyperemesis Gravidarum

Definition: Pernicious vomiting during pregnancy. Usually develops during first 3 months of pregnancy.


A. Cause unclear but may be caused by the addition of new substances to the body system—a toxicity or maladjustment of the maternal metabolism.

B. HCG and estrogen increase and are believed to play a role.

C. Increased incidence of Helicobacter pylori (stomach ulcers).


A. Check for persistent nausea and amount of vomiting.

B. Assess for abdominal pain and hiccups.

C. Measure weight loss (5% of pregnancy weight).

D. Evaluate dehydration status caused by excessive-vomiting.

E. Assess electrolyte imbalance: depletion of essential electrolytes because of unreplaced loss of sodium chloride and potassium.

F. Assess for metabolic acidosis: acetone odor to breath.

G. Evaluate increase in blood urea nitrogen (BUN).

H. Assess for hypoproteinemia and hypovitaminosis.


A. Use tact and understanding of the client’s problem.

B. Carefully record I&O; maintain IVs.

C. Provide attractive, small, low-fat meals, and remove dishes as soon as the client finishes eating.

D. Offer frequent, small feedings: small amounts every 2 hours, dry foods preferred. Offer liquids (herbal teas) between or after meals, rather than with meals.

E. Provide dietary sources of potassium and magnesium, 1 g ginger.

F. Administer antiemetic, plus a tranquilizer or a sedative as ordered.

G. If vomiting is persistent:

1. Client is usually hospitalized.
2. Dehydration and starvation are treated by administration of parenteral fluids, total parenteral nutrition (TPN), and vitamin supplements.
3. Rest and sedatives are prescribed.
4. Psychotherapy if necessary.

H. Provide rest, reduce stimuli, and restrict visitors.

I. Monitor fetal heart rate.

J. Acupressure at P6 acupuncture site.




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