Ch. 25

Select all the signs and symptoms listed that may indicate hypovolemic shock.

-fetal tachycardia -decreased blood pressure -cold and clammy skin

Which of the following women are at higher risk for an ectopic pregnancy?

-history of pelvic infection -had tubal ligation 1 year ago -conception was by assisted reproduction -history of intrauterine contraceptive device -had five therapeutic abortions

Although the cause of preeclampsia is not understood, there are several factors known to increase a woman's risk. Select all the following that are risk factors for preeclampsia.

-prepregnancy diabetes -first baby -african american -mulitfetal pregnancy -family history

A woman is admitted to the maternity unit with preeclampsia. She is started on magnesium sulfate IV, a urinary catheter is inserted, and she is put on bed rest. The nurse understands it is important to monitor urinary output hourly. It is important that the client have an output of at least:

30ml Rationale:Normal renal profusion should be an hourly output of at least 30 mL. Decreased urinary output indicates poor perfusion of the kidneys and may precede acute renal failure.

A woman in labor has a long history of uncontrolled hypertension. The hypertension has continued throughout the pregnancy and labor. The nurse is aware that the woman is at high risk for which complication?

Abruptio placentae Rationale: Risk factors for abruptio placentae include maternal hypertension. Vasoconstriction is an effect of hypertension that can affect the endometrial arteries.

During the nursing assessment at a routine prenatal visit, the woman's blood pressure was significantly higher than the last visit. Because of this finding, the nurse should:

Check the urine for presence of protein. Rationale:The two classic signs of preeclampsia are hypertension and proteinuria. Edema in the feet is common in most pregnancies. Edema with preeclampsia may continue up the legs to the hands and face.

When doing a chart review of a client with preeclampsia, the nurse noted that the client was assessed with +3 edema. This indicates:

Edema of lower extremities, face, hands, and sacral area.

A pregnant woman at 36 weeks of gestation is admitted to the high-risk pregnancy unit with hypertension. Assessment findings indicate severe preeclampsia. The nurse should:

Expect a maintenance dose of intravenous magnesium sulfate to be about 2g/hr. Rationale:The woman should be assigned to a private room in a quiet area because she is at risk for seizures, which can be precipitated by any sudden activity or sound. Although her diet should contain complex carbohydrates, protein content should be normal to replace protein losses in urine; low-salt diets are not recommended. While on bed rest, the woman should alternate her position from side to side to facilitate placental and renal perfusion, which will enhance cardiac output and facilitate loss of retained fluid.

The acronym for hemolysis, elevated liver enzyme levels, and low platelets that describes a life-threatening occurrence during pregnancy is __________________.

HELLP

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time, she is at greatest risk for:

Hemorrhage Rationale:Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site but is not a priority concern at this time. There is no greater risk for urinary retention or thrombophlebitis than with a normally implanted placenta.

During pregnancy a woman has an indirect Coombs test done. The nurse can teach her that this test will show:

Her previous exposure to Rh-positive blood. Rationale:Rh-negative women should have an indirect Coombs test to determine whether they are sensitized (have developed antibodies) as a result of previous exposure to Rh-positive blood.

A woman has just had a spontaneous abortion. She asks the nurse, "Why did this happen?" The nurse is aware that the most common cause of spontaneous abortion is:

Severe congenital abnormalities. Rationale:Chromosomal abnormalities account for about 50% to 60% of early spontaneous abortions. Other possible causes are various types of infections and maternal disorders.

A 20-week-pregnant client attending her first prenatal visit tells the nurse at the maternity clinic that she has had vaginal bleeding and excessive nausea and vomiting for the past 3 days. The nurse assesses her blood pressure at 142/95 mm Hg, pulse 86 bpm, respirations 16 breaths/min. When the nurse helps the client onto the examining table, the abdomen looks larger than normal for a 20-week pregnancy. The nurse is aware that these are signs of:

Hydatifiform mole Rationale:Signs and symptoms of a hydatidiform mole pregnancy include a uterus that is larger than expected, vaginal bleeding, excessive nausea and vomiting, and early development of preeclampsia.

The nurse is admitting 37-week-pregnant woman with severe preeclampsia. When choosing a room for her, the nurse would put her in the:

Last room at the end of the hall, close to the nurses' station. Rationale:The mother needs to be closely monitored. However, she also needs an area that is away from external stimuli and is quiet. All the other rooms would have visitors and noise associated with them.

Rh factor incompatibility can occur only in which of the following situations?

Mother is Rh-negative, father is Rh-positive Rationale:Rh incompatibility during pregnancy is possible only when the mother is Rh-negative and the fetus is Rh-positive. For the fetus to be Rh-positive, the father must be Rh-positive. Rh-negative blood is an autosomal recessive trait and a person must inherit the same gene from both parents.

A woman is admitted with a diagnosis of missed abortion. After taking her blood pressure, the nurse notices petechiae on the woman's arm where the cuff was located. The nurse's next action should be to:

Notify the health care provider Rationale:One major complication of missed abortion is disseminated intravascular coagulation (DIC). This may be manifested by small areas of hemorrhaging. The health care provider needs to be notified.

During labor, a woman suddenly complains of increasing pain, and the electronic monitor shows no uterine activity. The abdomen is boardlike and tender and the fetal heart tones show late decelerations. The nurse should:

Notify the health care provider Rationale:With abruptio placentae, the uterus may become exceedingly firm and tender. Because of decreased blood flow, the fetus will show signs of hypoxia. An immediate cesarean birth may be necessary; therefore the health care provider should be notified.

Signs of a threatened abortion are noted in a woman at 8 weeks of gestation. Which of the following is an appropriate management approach for this type of abortion?

Prepare the woman for an ultrasound to determine the integrity of the gestational sac. Rationale:A D&C is not considered until signs of progress to inevitable abortion are noted or the contents expelled are incomplete. Bed rest is not recommended for this woman, just a decrease in activities. Telling the woman she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy. If the pregnancy is lost, she should be guided through the grieving process.

A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. The primary goal of her treatment at this time would be to:

Reverse fluid, electrolyte, and acid-base imbalances that are present. Rationale:Fluid, electrolyte, and acid-base imbalances present the greatest immediate danger to the well-being of the maternal-fetal unit. Options A, B, and D are all components of treatment but do not represent immediate care for patients with hyperemesis gravidarum.

A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment will be evaluated as successful if:

Seizures do not occur. Rationale:Magnesium sulfate is a CNS depressant given primarily to prevent seizures. A temporary decrease in blood pressure can occur, but is not the purpose for giving the medication. Hypotonia is a sign of an excessive serum level of magnesium, as is depression of respiratory activity. If is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not a priority outcome of magnesium sulfate administration.

A woman has just been admitted to the maternity unit with a diagnosis of incomplete abortion. The physician has written the following orders: (1) NPO (2) Type and crossmatch for two units of blood. (3) Start intravenous line and run Ringer's lactate at 150 mL/hr. (4) Administer Pitocin, 10 units intramuscular. (5) Acetaminophen and codeine (Tylenol with Codeine #3), every 3 to 4 hours as needed for pain (6) Bed rest with bathroom privileges Which order should the nurse carry out first for this patient?

Start the IV and draw blood to send for the type and crossmatch. Rationale:Initial treatment of an incomplete abortion should focus on stabilizing the woman cardiovascularly. She may have lost blood or is at high risk for blood loss, so it is important to have her typed and crossmatched for replacement blood. The IV will help with fluid replacement.

A 32-week-pregnant woman calls the prenatal clinic complaining of bleeding without pain or contractions. The nurse should:

Tell her to go the hospital to be evaluated Rationale:Signs of placenta previa are painless bleeding after 20 weeks of gestation. Active bleeding can occur; therefore she needs to be evaluated.

The loss of the pregnancy before the fetus is viable or capable of living outside the uterus is termed a(n)

abortion

When a pregnant woman progresses from preeclampsia to generalized seizures that cannot be attributed to other causes, it is called

eclampsia

An abortion is usually ________________ when the membranes rupture and the cervix dilates.

inevitable

A condition in which hypertension develops during the last half of pregnancy in a woman who previously had normal blood pressure is called ___________________.

preeclampsia

A pregnant woman should be taught that the first sign of a threatened abortion is usually:

vaginal bleeding Rationale:The first sign of threatened abortion is vaginal bleeding, which is rather common during early pregnancy. One third of pregnant women experience bleeding in early pregnancy and up to 50% of these pregnancies end in A spontaneous abortion. The vaginal bleeding may be followed by uterine cramping and backache.