Chapter 9

Antepartum Case Study A Answers

1. Abnormal findings requiring follow-up:

• Fundal height measurement (35 cm at 38 weeks): A discrepancy of more than 2 cm between fundal height and gestational age warrants further investigation. Potential causes include intrauterine growth restriction (IUGR), oligohydramnios, or a transverse/oblique fetal position.
• Blood pressure (140/94 mmHg): Elevated BP suggests possible gestational hypertension or preeclampsia, especially with the trace protein in the urine.
• Hemoglobin (10.1 mg/dL): Indicates mild anemia, which is common in pregnancy but may require supplementation or dietary changes.
• Urine dipstick test (trace protein and 1+ glucose): Trace protein could be related to preeclampsia, and 1+ glucose warrants monitoring for potential gestational diabetes, especially in late pregnancy.
• Group B Streptococcus (GBS) positive: This requires intrapartum prophylaxis with antibiotics to prevent neonatal infection.
• Rubella non-immune status: Although vaccination is contraindicated during pregnancy, this must be addressed postpartum to prevent future rubella infection during subsequent pregnancies.

2. Health Teaching and Anticipatory Guidance

If the client reports headaches, visual disturbances, or epigastric pain: Advise immediate medical evaluation as these are warning signs of severe preeclampsia.
If the client reports vaginal bleeding or decreased fetal movement: Emphasize contacting the healthcare provider immediately, as these could indicate placental issues or fetal distress.

Provide education on signs of labor versus false labor.

• True labor: Contractions increase in intensity, are regular, and accompanied by cervical dilation or rupture of membranes.
  False labor: Irregular contractions relieved by walking or changing positions.

Management of current symptoms:

• Increased urination and easier breathing: Explain that these are likely caused by lightening, where the baby moves lower into the pelvis, preparing for birth.
• Increased vaginal discharge: Reassure the client that this is common in late pregnancy, but any foul smell, greenish discharge, or itching should prompt evaluation for infection.
• Group B Strep positive: Educate on the need for IV antibiotics during labor to prevent transmission to the newborn.
• Nutritional guidance for anemia: Encourage iron-rich foods (e.g., leafy greens, lean meats, fortified cereals) and iron supplementation as prescribed. Advise taking iron with vitamin C to enhance absorption and avoiding calcium-rich foods simultaneously.
• Rubella vaccination postpartum: Highlight the importance of receiving the MMR vaccine postpartum to ensure immunity before future pregnancies.

Antepartum Case Study B

1. Multiparity can significantly impact a mother’s adaptation to pregnancy. Unlike first-time mothers, multiparous clients often prioritize the needs of their existing children over their own, which can lead to less focus on self-care and emotional preparation for the new baby. This pregnancy may feel less novel, shifting attention to concerns about how the family will adapt. For example, the client’s worry about her two-year-old accepting the new baby reflects the common challenge of balancing the demands of multiple children. The emotional strain of managing a growing family may also be heightened by concerns about support from the partner, who may be less involved than in prior pregnancies. These factors can create a sense of isolation and amplify feelings of inadequacy, potentially overshadowing the natural excitement that often accompanies pregnancy.

2. To address the client’s concerns, the nurse should start by validating her emotions and offering empathetic listening. A statement like, “It’s completely understandable to feel overwhelmed when thinking about your child’s adjustment and your partner’s support,” can reassure the client that her feelings are normal. Providing practical strategies for sibling adjustment is key, such as involving the two-year-old in baby preparations and reassuring them of their unique place in the family. To address the client’s concern about her partner’s emotional distance, the nurse can encourage open communication between the couple, suggesting ways to involve the partner in prenatal care, such as attending appointments or preparing for the baby together. If the client’s apathy and worry appear profound, screening for prenatal depression or anxiety is essential, with referrals to counseling or support services if needed. The nurse can also emphasize the importance of self-care and connecting with a support network, such as friends, family, or parent groups, to help manage emotional and practical challenges. By blending practical advice with emotional support, the nurse can help the client feel more confident and supported in navigating her pregnancy.

Antepartum Case Study C

1. Gravida refers to the total number of pregnancies, including the current one, while para refers to the number of pregnancies carried to viability (typically after 20 weeks), regardless of the number of infants born. For this client, her gravida para history is G3P1, indicating three pregnancies (twins pregnancy, spontaneous abortion, and current pregnancy) and one pregnancy carried to viability (the twins born at 38 weeks).

2. A non-stress test (NST) is a non-invasive procedure used to evaluate fetal well-being by monitoring the fetal heart rate (FHR) in response to fetal movements. During the test, the client is connected to an external fetal monitor, and the FHR is observed for 20 to 40 minutes. A healthy fetus shows accelerations in heart rate in response to movement, which indicates proper oxygenation and a well-functioning autonomic nervous system. A reactive NST, the desired outcome, is characterized by at least two FHR accelerations within 20 minutes, with each acceleration being at least 15 beats per minute above the baseline and lasting at least 15 seconds (for fetuses >32 weeks). A non-reactive NST, on the other hand, occurs when these criteria are not met, which may suggest fetal hypoxia, prolonged sleep cycles, or other concerns that require follow-up testing, such as a biophysical profile or contraction stress test.

3. A reactive non-stress test is a sign of fetal well-being, indicating adequate oxygenation and nervous system function. To be classified as reactive, the NST must show at least two accelerations in the fetal heart rate within a 20-minute window, with each acceleration being 15 beats per minute above the baseline and lasting for at least 15 seconds in fetuses over 32 weeks. A non-reactive NST, however, lacks sufficient accelerations during the observation period, raising concerns about potential fetal hypoxia, prolonged fetal inactivity, or other underlying issues. In such cases, further evaluation with a biophysical profile or additional diagnostic testing is recommended.

4. The biophysical profile (BPP) is a comprehensive assessment tool combining a non-stress test with four ultrasound-based evaluations to assess fetal well-being. Each component is scored on a scale of 0 to 2, with a total score of 8-10 being reassuring, 6 considered equivocal, and ≤4 requiring further evaluation or delivery. The components include fetal heart rate reactivity from the NST, fetal breathing movements (at least one episode lasting 30 seconds within 30 minutes), fetal movement (at least three discrete movements within 30 minutes), fetal tone (at least one episode of active extension and flexion of a limb or trunk), and amniotic fluid volume (a pocket measuring at least 2 cm in two perpendicular planes). The BPP provides a detailed picture of fetal health and helps guide clinical decision-making.

Please find answers to the Learning Activity interactive elements within the element.