Chapter 38 The Obstetric Patient

A multiparous woman was admitted at 36 weeks' gestation for nausea, vomiting, and severe epigastric pain. The fetal heart rate was normal. Severe preeclampsia was diagnosed. The patient is placed on a magnesium sulfate drip of 3 g/h. After an hour the patient has a seizure. The nurse notifies the practitioner. What order would the nurse anticipate? a.Administer another 2- to 4-g bolus of magnesium sulfate. b.Increase the magnesium drip at a rate of 1 to 2 g/h. c.Prepare the patient for immediate delivery of the baby. d.Prepare for intubation and mechanical ventilatory support.

ANS: A Control of eclamptic seizures is accomplished through administration of 4 to 6 g of intravenous MgSO4 over 5 to 10 minutes. This bolus is followed by a continuous infusion of 2 to 3 g/h. If a patient has a recurrent seizure, another 2- to 4-g bolus can be given over 3 to 5 minutes.

A patient who is 32 weeks pregnant is admitted with a pneumothorax. What must the practitioner consider when placing a chest tube? a.The diaphragm has been displaced 4 cm upward from its original location. b.The diaphragm has been flattened and displaced 2 cm downward. c.The lungs have shrunk to accommodate for the increase in abdominal size. d.The lower lobes are one-half of their original size.

ANS: A During pregnancy, as the uterus grows, the maternal diaphragm is displaced 4 cm above its normal location. This change in location must be considered if placement of a chest tube is necessary to avoid injury to the diaphragm. The insertion point during pregnancy is usually between the third and fourth intercostal spaces.

Which statement regarding the use of medications or other therapies for advanced cardiac life support (ACLS) in the pregnant patient is accurate? a.No contraindications exist for use of atropine in pregnancy. b.Epinephrine is contraindicated because it decreases uteroplacental perfusion. c.Lidocaine is contraindicated because it crosses the placenta and has adverse fetal effects. d.Electric therapies are contraindicated because of the potential for electrocution of the infant.

ANS: A No contraindications exist for use of atropine in pregnancy. Epinephrine may decrease uteroplacental perfusion because of its vasoconstrictive nature; however, the benefits outweigh the risks of administration. Lidocaine crosses the placenta but in therapeutic levels does not have adverse fetal or uteroplacental effects. Electric therapies such as defibrillation, cardioversion, and pacing are not contraindicated in pregnancy, but all fetal monitoring devices should be removed because a theoretical risk of the scalp electrode arcing and electrocuting the infant does exist.

A patient has been admitted with severe preeclampsia. The nurse understands the patient is at risk for hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. What clinical manifestations would indicate the patient is developing this condition? a.Nausea, vomiting, and epigastric pain b.Jaundice, pruritus, and flank pain c.Hypoactive bowel sounds, bleeding at puncture sites, and back pain d.Fever, jugular vein distention, and chest pain

ANS: A The clinical manifestations of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, which include nausea, vomiting, malaise, flulike symptoms, and epigastric pain, may suggest a multitude of other clinical diagnoses. Misdiagnosis is common and may result in a delay of correct treatment. HELLP syndrome may be confused with acute renal disease, gastroenteritis, hepatitis, gallbladder disease, pyelonephritis, or thrombotic thrombocytopenic purpura.

A patient is admitted who is pregnant and has a congenital cardiac disorder. The patient is experiencing complications that include dysrhythmias, heart failure, and thromboembolism. The nurse recognizes that these are symptoms of which condition? a.Atrial septal defect b.Ventricular septal defect c.Patent ductus arteriosus d.Mitral stenosis

ANS: A The most common complications seen with atrial septal defect (ASD) are dysrhythmias, heart failure, and thromboembolism. Complications of ventricular septal defect include tachycardia, heart failure, and pulmonary hypertension. Complications of patent ductus arteriosus include large left-to-right shunts, causing congestive heart failure or pulmonary hypertension. Complications of mitral stenosis include thromboembolism; heart failure; and arrhythmias, especially atrial fibrillation.

A patient has been admitted with severe preeclampsia. The nurse knows that the patient's treatment plan would include which goals? (Select all that apply.) a.Prevention of seizures b.Decreasing arterial spasms c.Prompt delivery of the fetus d.Support of hypotension e.Administration of broad-spectrum antibiotics

ANS: A, B, C Controlling seizures and decreasing arterial spasm are essential in treating preeclampsia; patients are usually hypertensive, and antibiotics are not necessary.

What factors must be considered when making clinical decisions regarding critically ill obstetric patients? (Select all that apply.) a.Maternal-fetal mortality b.Parental desires c.Fetal weight d.Parameters of maternal age e.Parameters of gestational age

ANS: A, B, C, E Critical care clinicians may encounter situations in which extrauterine viability, fetal outcomes, and maternal stability are uncertain. Clinical decisions must be made in light of the maternal-fetal risk-benefit ratio. Personal, cultural, spiritual, and social beliefs regarding viability may affect the clinical decision-making process. Parental and family beliefs and desires may conflict with those of the health care team. When confronting the dilemma of viability, the parameters of gestational age, fetal weight, parental desires, and maternal-fetal mortality must be considered.

Which obstetric conditions may precipitate disseminated intravascular coagulation (DIC) in an obstetric patient? (Select all that apply.) a.Abruptio placentae b.Amniotic fluid embolism c.Asthma d.Intracranial hemorrhage e.Bacterial pneumonia f.Dead fetus syndrome

ANS: A, B, F Abruptio placentae, amniotic fluid embolism, and dead fetus syndrome can result in the development of disseminated intravascular coagulation (DIC).

What are some of the unique causes of septic shock in pregnant patients? (Select all that apply.) a.Postpartum pyelonephritis b.Ectopic pregnancy c.Chorioamnionitis d.Septic abortion e.Postpartum hemorrhage

ANS: A, C, D Unique causes of septic shock in pregnant patients include chorioamnionitis, septic abortion, and postpartum pyelonephritis. Causes of hemorrhagic shock unique to pregnancy include abruptio placentae, ectopic pregnancy, placenta previa, and postpartum hemorrhage.

What is the most common obstetric cause of disseminated intravascular coagulopathy (DIC)? a.Preeclampsia b.Abruptio placentae c.Dead fetus syndrome d.Amniotic fluid embolism

ANS: B Although all of these above conditions can cause disseminated intravascular coagulopathy (DIC), abruptio placentae is the most common obstetric cause of DIC.

A patient has been admitted with preeclampsia. The nurse understands that this disorder is characterized by what widespread physiologic changes? a.Increase in circulating plasma volume b.Vasospasms in the arterial system c.Disseminated intravascular coagulation d.High systemic vascular resistance

ANS: B Characteristics of preeclampsia include widespread arteriolar vasospasms, resulting in decreased perfusion to virtually all organs, including the placenta; a decrease in plasma volume; activation of coagulation cascade; and alteration in glomerular capillary endothelium. These generalized cyclic vasospasms lead to tissue ischemia and eventually end-organ dysfunction.

What intrinsic factor can influence fetal development? a.Fungal infections b.Chromosomal abnormalities c.Radiation exposure d.Medication exposure

ANS: B Intrinsic factors such as chromosomal abnormalities and congenital anomalies account for 25% of all birth defects. Extrinsic factors such as radiation exposure; bacterial, fungal, and viral infections; medication exposure; and "unknown" causes account for the remainder.

What is the leading cause of maternal trauma? a.Burns b.Motor vehicle accident c.Falls d.Domestic violence

ANS: B Motor vehicle accidents (MVAs) are the leading cause of maternal blunt trauma and account for 55% to 82% of maternal trauma.

Which statement regarding pregnancy and asthma is accurate? a.Progesterone causes smooth muscle relaxation, which can worsen asthma symptoms. b.Poorly controlled asthma has been associated with an increased incidence of spontaneous abortion. c.A decrease in peak expiratory flow rate (PEFR) of more than 20% of the patient's personal best requires a visit to the emergency room. d.It is estimated that approximately two thirds of patients will have worsening of asthma symptoms.

ANS: B Poorly controlled asthma during pregnancy has been associated with an increased incidence of spontaneous abortion. The lessening of asthma symptoms during pregnancy is the result of smooth muscle relaxation caused by progesterone. A decrease in peak expiratory flow rate (PEFR) of more than 20% of the patient's personal best requires a call to the physician; a decrease to of greater than 50% of the patient's personal best signals the need for a visit to the emergency department and the need for rapid assessment and intervention. It is estimated that approximately one third of patients will experience no change in asthma symptoms, one third will see improvement, and one third will have worsening of symptoms.

A patient has been admitted with severe preeclampsia. The nurse knows that the patient's treatment plan would include which intervention? a.Titrating intravenous fluids to maintain urine output greater than 50 mL/h b.Administering hydralazine to keep the systolic blood pressure less than 120 mm Hg c.Placing the patient on bed rest to decrease the chance of delivery d.Administering magnesium sulfate to maintain serum levels of 4 to 7 mEq/L

ANS: B Severe hypertension must be addressed after magnesium infusions. Antihypertensive agents need to be used to keep diastolic blood pressure between 90 and 100 mm Hg. The main drugs used to achieve this are hydralazine hydrochloride and labetalol. Diuretics are used only in the setting of pulmonary edema. The placenta plays a central role in the development of the disease, for which the only known cure is delivery of the fetus and removal of the placenta.

What conditions or disorders place the obstetric patient at a 25% to 50% risk of maternal mortality? (Select all that apply.) a.Marfan syndrome with valvular involvement b.Pulmonary hypertension c.Coarctation of aorta with valvular involvement d.Marfan syndrome with aortic involvement e.Mitral stenosis with atrial fibrillation

ANS: B, C, D Maternal mortality risks are as follows. Group 3: Mortality rate, 25% to 50%. Risks for this group include pulmonary hypertension, coarctation of the aorta with valvular involvement, and Marfan syndrome with aortic involvement. Group 2: Mortality rate, 5% to 15%. Risks for group 2A include mitral stenosis, New York Heart Association classes III and IV; aortic stenosis; coarctation of aorta without valvular involvement; tetralogy of Fallot, uncorrected; previous myocardial infarction; and Marfan syndrome with a normal aorta. Risks for group 2B include mitral stenosis with atrial fibrillation and artificial valve.

Which physiologic changes are common in pregnant women? (Select all that apply.) a.Circulating blood volume decreases by 20% as it is diverted to the placenta. b.Oxygen consumption increases to accommodate the fetus's needs. c.Respiratory tidal volumes decrease because of the elevated diaphragm. d.Gastric motility decreases because of displacement of gastrointestinal structures by the enlarged uterus. e.The glomerular filtration rate increases as cardiac output rises.

ANS: B, D, E Blood volumes increase and cardiac output rises to accommodate fetal circulation. The enlargement of the uterus pushes the abdominal contents upward, impairing gastric function.

What is the second leading cause of maternal death in the United States? a.Sepsis b.Hemorrhage c.Hypertensive disease d.Disseminated intravascular coagulation

ANS: C Hypertensive disease is present in up to 5% of pregnant women. It is the second leading cause of death in childbearing women, and it contributes to high rates of newborn morbidity and mortality.

The nurse is caring for a patient with preexisting spinal cord injury (SCI) who is 37 weeks pregnant. The SCI occurred at T4. Which intervention would be added to the plan of care when the patient goes into labor? a.Instruct the patient to let the nurse know when labor starts. b.Administer steroids at the onset of labor. c.Monitor the patient for signs of autonomic dysreflexia. d.Prepare the patient for a cesarean section.

ANS: C Patients with injuries above T6 are at risk for developing autonomic dysreflexia reaction (ADR) and may require assisted vaginal delivery or a cesarean section. Vaginal delivery with a spinal cord injury (SCI) is possible. Uterine sensory nerves enter the spinal cord at T11 to L1; women with SCI above T10 are, therefore, unable to feel uterine contractions. Steroids may be used for the initial management of SCI and are not part of the labor process.

he mnemonic "tone, tissue, trauma, and thrombosis" refers to potential causes of which disorder? a.Hypoxia b.Abruptio placentae c.Postpartum hemorrhage (PPH) d.Trauma

ANS: C Postpartum hemorrhage (PPH) has many potential causes. As a way of remembering the causes of PPH, several sources have suggested using the "4 T's" as a mnemonic: tone, tissue, trauma, and thrombosis.

According to research, what are the minimal viability parameters for an infant? a.20 to 21 weeks' gestation and fetal weight between 500 and 1000 g. b.22 to 23 weeks' gestation and fetal weight between 1000 and 15,000 g. c.23 to 24 weeks' gestation and fetal weight between 500 and 1000 g. d.24 to 25 weeks' gestation and fetal weight between 500 and 1200 g.

ANS: C Research has placed minimal viability parameters between 23 and 24 weeks' gestation and fetal weight between 500 and 1000 g (0.5 and 1 kg).

A patient who is 30-weeks pregnant is admitted with severe asthma. The nurse understands that sufficient fetal oxygenation requires what minimum level of maternal oxygenation? a.PaO2 greater than 100 mm Hg b.PaO2 greater than 70 mm Hg c.Oxygen saturation of 100% d.Oxygen saturation greater than 70%

ANS: C Sufficient fetal oxygenation requires a maternal arterial oxygen tension (PaO2) greater than 70 mm Hg, which corresponds to an oxygen saturation of 95%.

The treatment plan for management of an obstetric patient with peripartum cardiomyopathy (PPCM) includes which interventions? a.Oxygen therapy, pain management, and preload enhancement b.Walking exercises, diuretics, and anticoagulants c.Diuretics, digoxin, and anticoagulation d.Fluid resuscitation, beta-blockers, and vasoconstrictors

ANS: C Symptoms are identical to those of classic cardiac failure, but treatment depends on the pregnancy status of the patient. Women who present with peripartum cardiomyopathy (PPCM) during pregnancy require joint cardiac and obstetric care, but as soon as the baby is born and the patient is hemodynamically stable, standard therapy for heart failure may be applied. This would include treatment with diuretics, digoxin, beta-blockade, and afterload reduction. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and renin inhibitors are contraindicated during pregnancy because of fetotoxicity but may be used after the infant is born. After the bleeding has been stopped after delivery, anticoagulation is commonly used to prevent thromboembolism and the formation of left ventricular thrombus, which is associated with a worse prognosis.

A multiparous woman was admitted at 36 weeks' gestation for nausea, vomiting, and severe epigastric pain. The fetal heart rate was normal. Severe preeclampsia was diagnosed. What is the treatment goal for this patient? a.Maintaining maternal blood pressure greater than 140/90 mm Hg b.Delaying delivery of the fetus as long as possible c.Preventing maternal seizures, which may compromise fetal oxygenation d.Limiting fluid intake to avoid postpartum edema.

ANS: C The treatment goals of severe preeclampsia are to prevent seizures, decrease arterial spasms, and effect prompt delivery of the fetus. MgSO4 is the standard treatment for prevention and control of seizure activity in preeclampsia and eclampsia.

A multiparous woman was admitted at 36 weeks' gestation for nausea, vomiting, and severe epigastric pain. The fetal heart rate was normal. Severe preeclampsia was diagnosed. In addition to her clinical signs and symptoms, the patient's laboratory studies demonstrate hemolysis of red blood cells, elevated liver enzymes, and a low platelet count. What would be anticipated as an additional diagnosis? a.Disseminated intravascular coagulopathy (DIC) b.Dead fetus syndrome c.Amniotic fluid embolism d.HELLP syndrome

ANS: D Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is an associated syndrome that affects 4% to 12% of patients with severe preeclampsia or eclampsia. The maternal mortality rate ranges from 3.5% to 24%, and the perinatal mortality rate ranges from 10% to 60%.

A patient is brought to the unit after delivering a very large baby. The patient suddenly becomes extremely agitated and complains of shortness of breath. An amniotic fluid embolism is suspected. The nurse would immediately prepare for which intervention? a.Insertion of a pulmonary artery catheter b.Administration of an ampule of 50% dextrose c.Administration of magnesium sulfate d.Intubation and mechanical ventilation

ANS: D Management consists of maintaining oxygenation and supporting cardiac function. Supportive therapy consists of maintenance of blood pressure through aggressive volume replacement and inotropic support, intubation and mechanical ventilation, and blood component therapy for hemorrhage. Other therapies such as low-dose heparin, bronchodilators, and steroids may be used.

A patient is admitted who is pregnant and has Marfan syndrome. The nurse knows that this disorder places the patient at risk for what complication? a.Stroke b.Pulmonary embolism c.Heart failure d.Aortic dissection

ANS: D Marfan syndrome is an autosomal dominant disorder of connective tissue in which serious cardiovascular involvement, usually dissection or rupture of the aorta, may occur.

What is the most common cause of obstetric cardiac arrest in pregnancy? a.Anesthetic complications b.Idiopathic peripartum cardiomyopathy c.Pregnancy-induced hypertension d.Hemorrhage

ANS: D Obstetric causes for cardiac arrest in pregnancy are hemorrhage (17%), pregnancy-induced hypertension (16%), idiopathic peripartum cardiomyopathy (8%), and anesthetic complications (2%).

When is the greatest risk for the patient who has had a cesarean section to develop a pulmonary embolism? a.First time patient gets out of bed b.Postoperative day 2 c.During the procedure d.Immediate postpartum period

ANS: D The greatest risk for developing pulmonary embolism is in the immediate postpartum period, especially if a cesarean section was performed.

What is the leading cause of cardiac arrest in pregnancy? a.Sepsis b.Pregnancy-induced hypertension c.Hemorrhage d.Pulmonary embolism

ANS: D The leading cause of cardiac arrest in pregnancy is pulmonary embolism, followed by hemorrhage, pregnancy-induced hypertension, and sepsis.