Chp 7: High-Risk Antepartum Nursing Care

Which of the following assessments would indicate instability in the client hospitalized for placenta previa? a. BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPM b. FHR moderate variability without accelerations c. Dark brown vaginal discharge when voiding d. Oral temperature of 99.9F

ANS: A A decrease in BP accompanied by bradycardia or tachycardia is an indication of hypovolemic shock. FHR with moderate variability can be absent of accelerations during fetal sleep cycles or after maternal sedation. Bright red vaginal bleeding is an indication of current bleeding. Oral temperature may fluctuate based on the client's hydration status. It should be reassessed. Cause for concern is a temperature of 100.4 F or more.

The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 weeks' gestation. The nurse is preparing to administer the second dose of beta-methasone prescribed by the physician. Marilyn asks: "What is this injection for again?" The nurse's best response is: a. "This is to help your baby's lungs to mature." b. "This is to prepare your body to begin the labor process." c. "This is to help stabilize your blood pressure." d. "This is to help your baby grow and develop in preparation for birth."

ANS: A Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours.

For the patient with which of the following medical problems should the nurse question a physician's order for beta agonist tocolytics? a. Type 1 diabetes mellitus b. Cerebral palsy c. Myelomeningocele d. Positive group B streptococci culture

ANS: A Beta agonists often elevate serum glucose levels. The nurse should question the order. Beta agonists are not contraindicated for patients with cerebral palsy. Beta agonists are not contraindicated for patients with myelomeningocele. Beta agonists are not contraindicated for patients with group B streptococci.

Which of the following nursing diagnoses is of highest priority for a client with an ectopic pregnancy who has developed disseminated intravascular coagulation (DIC)? a. Risk for deficient fluid volume b. Risk for family process interrupted c. Risk for disturbed identity d. High risk for injury

ANS: A Correct. The client is at high risk for hypovolemia which is life threatening and takes precedence over any psychosocial or less pressing diagnoses. This is a psychosocial diagnosis and is not life threatening. This is a psychosocial diagnosis and is not life threatening. The client is at risk for injury; however, the diagnosis of deficient fluid volume is more descriptive and has clearly defined goals and interventions.

Identify the hallmark of placenta previa that differentiates it from abruptio placenta. a. Sudden onset of painless vaginal bleeding b. Board-like abdomen with severe pain c. Sudden onset of bright red vaginal bleeding d. Severe vaginal pain with bright red bleeding

ANS: A Correct. When the placenta attaches to the lower uterine segment near or over the cervical os, bleeding may occur without the onset of contractions or pain. The hallmark for abruptio placenta is pain and a board-like abdomen. Bright red bleeding could be related to abruptio placenta, placenta previa, or other complications of pregnancy. Pain is not a hallmark of placenta previa.

Metabolic changes during pregnancy __________ glucose tolerance. a. lower b. increase c. maintain d. alter

ANS: A Metabolic changes during pregnancy lower glucose tolerance.

A primiparous woman has been admitted at 35 weeks' gestation and diagnosed with HELLP syndrome. Which of the following laboratory changes is consistent with this diagnosis? a. Hematocrit dropped to 28%. b. Platelets increased to 300,000 cells/mm3. c. Red blood cells increased to 5.1 million cells/mm3. d. Sodium dropped to 132 mEq/dL.

ANS: A The nurse would expect to see a drop in the hematocrit: The H in HELLP stands for hemolysis. The nurse would expect to see low platelets. The nurse would expect to see hemolysis. The sodium is usually unaffected in HELLP syndrome.

Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae? a. Increasing abdominal girth measurements b. Profuse vaginal bleeding c. Bradycardia with an aortic thrill d. Hypothermia with chills

ANS: A The nurse would expect to see increasing abdominal girth measurements.Profuse vaginal bleeding is rarely seen in placental abruption and is never seen when the abruption is concealed.With excessive blood loss, the nurse would expect to see tachycardia.The nurse would expect to see a stable temperature.

Your antepartal patient is 38 weeks' gestation, has a history of thrombosis, and has been on strict bed rest for the last 12 hours. She is now experiencing shortness of breath. What about the patient may be a contributing factor for her shortness of breath? a. Physiologic changes in pregnancy result in vasodilation, which increases the tendency to form blood clots. b. Physiologic changes in pregnancy result in vasoconstriction, which increases the tendency to form blood clots. c. Physiologic changes in pregnancy result in anemia, which increases the tendency to form blood clots. d. Physiologic changes in pregnancy result in decreased perfusion to the lungs, which increases the tendency to form blood clots.

ANS: A The patient's shortness of breath, bed rest, and history of thrombosis indicate possible pulmonary embolism. Her pregnant state also increases the potential for thrombosis resulting from increased levels of coagulation factors and decreased fibrinolysis, venous dilation, and obstruction of the venous system by the gravid uterus. Thromboembolitic diseases occurring most frequently in pregnancy include deep vein thrombosis and pulmonary embolism.

Marked hemodynamic changes in pregnancy can impact the pregnant woman with cardiac disease. Signs and symptoms of deteriorating cardiac status include (select all that apply): a. Orthopnea b. Nocturnal dyspnea c. Palpitations d. Irritation

ANS: A, B, C Signs and symptoms of deteriorating cardiac status with cardiac disease include orthopnea, nocturnal dyspnea, and palpitations, but do not include irritation.

The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta previa risk factors include (select all that apply): a. Cocaine use b. Tobacco use c. Previous caesarean birth d. Previous use of medroxyprogesterone (Depo-Provera)

ANS: A, B, C Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age. Previous use of medroxyprogesterone (Depo-Provera) is not a risk factor for placenta previa.

The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information provided about preterm labor and birth prevention includes (select all that apply): a. Encouraging regular, ongoing prenatal care b. Reporting symptoms of urinary frequency and burning to the health-care provider c. Coming to the labor triage unit if back pain or cramping persist or become regular d. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5 minutes

ANS: A, B, C The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider if symptoms of preterm labor occur. Lying on the right side; drinking fluids, not withholding fluids; and counting fetal movements if contractions occur every 5 minutes are recommended if a woman thinks she is contracting.

Betamethasone is a steroid that is given to a pregnant woman with signs of preterm labor. The purpose of giving steroids is to (select all that apply): a. Stimulate the production of surfactant in the preterm infant b. Be given between 24 and 34 weeks' gestation c. Increase the severity of respiratory distress d. Accelerate fetal lung maturity

ANS: A, B, D Betamethasone is a steroid that is given to pregnant women with signs of preterm labor between 24 and 34 weeks' gestation. It stimulates the production of surfactant in the preterm infant and accelerates fetal lung maturity.

The perinatal nurse describes for the new nurse the various risks associated with prolonged premature preterm rupture of membranes. These risks include (select all that apply): a. Chorioamnionitis b. Abruptio placentae c. Operative birth d. Cord prolapse

ANS: A, B, D Even though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cord prolapse.

Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks' gestation. An appropriate nursing action would be to (select all that apply): a. Assess the fetal heart rate b. Obtain urine for culture and sensitivity c. Assess Kerry's blood pressure and pulse d. Palpate Kerry's abdomen for contractions

ANS: A, B, D Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient's abdomen should be palpated to assess for contractions, and the fetus's heart rate should be monitored. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency). The patient's abdomen should be palpated to assess for contractions, and the fetus's heart rate should be monitored. Assessment of blood pressure and pulse is not an important nursing action in this scenario. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient's abdomen should be palpated to assess for contractions and the fetus's heart rate should be monitored.

Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension? a. Total urine protein of 200 mg/dL b. Total platelet count of 40,000 mm c. Uric acid level of 8 mg/dL d. Blood urea nitrogen 24 mg/dL

ANS: B The client's urine protein is elevated. A urine protein of ≥300 mg/dL in a 24-hour collection is considered concerning. Correct. A platelet count of ≤50,000 is a critical value and should be reported to the health-care provider immediately. This client is at increased risk of hemorrhage. The uric acid level is only slightly elevated. The BUN is only slightly elevated.

While educating the client with class II cardiac disease, at 28 weeks' gestation, the nurse instructs the client to notify the physician if she experiences which of the following conditions? a. Emotional stress at work b. Increased dyspnea while resting c. Mild pedal and ankle edema d. Weight gain of 1 pound in 1 week

ANS: B Emotional stress increases cardiac workload; however, without symptoms of cardiac decompensation, this is not immediately concerning. Increasing dyspnea, at rest, can be a sign of cardiac decompensation leading to increased congestive heart failure. Mild edema during the third trimester is normal. However, increasing edema and pitting edema should be reported as they can be a sign of increasing CHF. A weight gain of 1 pound per week is expected during the third trimester.

A labor nurse is caring for a patient, 39 weeks' gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? a. Type and cross-match her blood. b. Insert an internal fetal monitor electrode. c. Administer an oral stool softener. d. Assess her complete blood count.

ANS: B It would be appropriate to type and cross-match the patient for a blood transfusion. This action is inappropriate. When a patient has a placenta previa, nothing should be inserted into the vagina. To prevent constipation, it is appropriate for a patient to take a stool softener. It is appropriate to monitor the patient for signs of anemia.

A 34-weeks' gestation multigravida, G3 P1 is admitted to the labor suite. She is contracting every 7 minutes and 40 seconds. The woman has several medical problems. Which of the following of her comorbidities is most consistent with the clinical picture? a. Kyphosis b. Urinary tract infection c. Congestive heart failure d. Cerebral palsy

ANS: B Kyphosis is unrelated to preterm labor. Urinary tract infections often precipitate preterm labor. It is unlikely that the congestive heart failure precipitated the preterm labor. Cerebral palsy is unrelated to preterm labor.

During pregnancy, poorly controlled asthma can place the fetus at risk for: a. Hyperglycemia b. IUGR c. Hypoglycemia d. Macrosomia

ANS: B Maternal asthma does not place the fetus at risk for hyperglycemia. Compromised pulmonary function can lead to decompensation and hypoxia that decrease oxygen flow to the fetus and can cause intrauterine growth restriction (IUGR). Asthma does not directly affect glycemic control. A fetus experiencing hypoxia would be small for gestational age, not large for gestational age.

Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client's blood glucose levels? a. Nifedipine b. Betamethasone c. Magnesium sulfate d. Indomethacin

ANS: B Nifedipine does not affect maternal blood glucose levels. Beta-sympathomimetics may stimulate hyperglycemia which will require an increased need for insulin. Magnesium sulfate does not affect blood glucose levels. Indomethacin does not affect blood glucose levels.

A woman at 10 weeks' gestation is diagnosed with gestational trophoblastic disease (hydatiform mole). Which of the following findings would the nurse expect to see? a. Platelet count of 550,000/ mm3 b. Dark brown vaginal bleeding c. White blood cell count 17,000/ mm3 d. Macular papular rash

ANS: B The nurse would not expect to see an elevated platelet count. The nurse would expect to see dark brown vaginal discharge The nurse would not expect to see an elevated white blood cell count. The nurse would not expect to see a rash.

A woman at 32 weeks' gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome? a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of polycythemia

ANS: C A rise in serum creatinine indicates that the kidneys are not effectively excreting creatinine. It is a negative outcome. A drop in serum protein indicates that the kidneys are allowing protein to be excreted. This is a negative outcome. Resolution of thrombocytopenia is a positive sign. It indicates that the platelet count is returning to normal. Polycythemia is not related to HELLP syndrome. Rather one sees a drop in red cell and platelet counts with HELLP. A positive sign, therefore, would be a rise in the RBC count.

A woman who is 36 weeks pregnant presents to the labor and delivery unit with a history of congestive heart disease. Which of the following findings should the nurse report to the primary health-care practitioner? a. Presence of chloasma b. Presence of severe heartburn c. 10-pound weight gain in a month d. Patellar reflexes +1

ANS: C Chloasma is a normal pregnancy finding. Heartburn is an expected finding during the third trimester. The weight gain may be due to fluid retention. Fluid retention may occur in patients with pregnancy-induced hypertension and in patients with congestive heart failure. The physician should be notified. Although slightly hyporeflexic, patellar reflexes of +1 are within normal limits.

You are caring for a patient who was admitted to labor and delivery at 32 weeks' gestation and diagnosed with preterm labor. She is currently on magnesium sulfate, 2 gm per hour. Upon your initial assessment you note that she has a respiratory rate of 8 with absent deep tendon reflexes. What will be your first nursing intervention? a. Elevate head of the bed b. Notify the MD c. Discontinue magnesium sulfate d. Draw a serum magnesium level

ANS: C Initial nursing intervention needs to be discontinuing magnesium sulfate because the patient is exhibiting signs of magnesium toxicity with absent deep tendon reflexes and decreased respiratory rate

A pregnant client with a history of multiple sexual partners is at highest risk for which of the following complications: a. Premature rupture of membranes b. Gestational diabetes c. Ectopic pregnancy d. Pregnancy-induced hypertension

ANS: C Multiple partners do not increase a woman's risk of premature rupture of membranes. Genetics and client diet and weight are contributing factors to gestational diabetes. Correct. A history of multiple sexual partners places the client at a higher risk of having contracted a sexually transmitted disease that could have ascended the uterus to the fallopian tubes and caused fallopian tube blockage, placing the client at high risk for an ectopic pregnancy. Multiple sexual partners are not a risk factor for pregnancy-induced hypertension.

A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings? a. Pyelonephritis b. Pregnancy-induced hypertension c. Gestational diabetes d. Abruptio placentae

ANS: C Pyelonephritis does not lead to the development of hydramnios or macrosomia. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings? a. Patellar and biceps reflexes of +4 b. Urinary output of 50 mL/hr c. Respiratory rate of 10 rpm d. Serum magnesium level of 5 mg/dL

ANS: C The magnesium sulfate has been ordered because the patient has severe pregnancy-induced hypertension. Patellar and biceps reflexes of +4 are symptoms of the disease. The urinary output must be above 25 mL/hr. The drop in respiratory rate may indicate that the patient is suffering from magnesium toxicity. The nurse should report the finding to the physician. The therapeutic range of magnesium is 4 to 7 mg/dL.

A woman who is admitted to labor and delivery at 30 weeks' gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour? a. Temperature b. Pulse c. Respiratory rate d. Blood pressure

ANS: C The temperature should be monitored, but it is not the most important vital sign. The pulse rate should be monitored, but it is not the most important vital sign. The respiratory rate is the most important vital sign. Respiratory depression is a sign of magnesium toxicity. The blood pressure should be monitored, but it is not the most important vital sign.

After an education class, the nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed? a. "I could get an STI even if I just have oral sex." b. "Girls over 16 are less likely to get STDs than younger girls." c. "The best way to prevent an STI is to use a diaphragm." d. "Girls get human immunodeficiency virus (HIV) easier than boys do."

ANS: C This statement is true. Organisms that cause sexually transmitted infections can invade the respiratory and gastrointestinal tracts. This statement is true. Young women are especially high risk for becoming infected with sexually transmitted diseases. This statement is untrue. The young woman needs further teaching. Condoms protect against STDs and pregnancy. In addition, condoms can be kept in readiness for whenever sex may occur spontaneously. Using condoms does not require the teen to plan to have sex. A diaphragm is not an effective infection-control method. Plus, it would require the teen to plan for intercourse. This statement is true. Young women are higher risk for becoming infected with HIV than are young men.

The perinatal nurse knows that tocolytic agents are most often used to (select all that apply): a. Prevent maternal infection b. Prolong pregnancy to 40 weeks' gestation c. Prolong pregnancy to facilitate administration of antenatal corticosteroids d. Allow for transport of the woman to a tertiary care facility

ANS: C, D Tocolytics are not used to treat maternal infection. Tocolytics are generally only effective in delaying delivery for several days. Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of antenatal corticosteroids to accelerate fetal lung maturity. Delaying the birth provides time for maternal transport to a facility equipped with a neonatal intensive care unit.

A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? a. High leukocyte count b. Explosive diarrhea c. Fractured pelvis d. Low platelet count

ANS: D High leukocyte count is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Explosive diarrhea is not associated with severe PIH or HELLP syndrome. A fractured pelvis is not associated with severe PIH or HELLP syndrome. Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure client safety. a. Assess uterine contractions continuously b. Assess fetal heart rate continuously c. Assess urinary output d. Assess respiratory rate

ANS: D Monitoring contractions does not indicate magnesium toxicity. Magnesium sulfate will decrease fetal variability and not provide an accurate assessment of magnesium toxicity. Urinary output does not correlate to decreased deep tendon reflexes. Correct. Respiratory effort and deep tendon reflexes (DTRs) are involuntary, and a decrease in DTRs could indicate the risk of magnesium sulfate toxicity and the risk for decreased respiratory effort.

The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? a. The patient with placenta previa b. The patient whose vagina is colonized with group B streptococci c. The patient who is hepatitis B surface antigen positive d. The patient with eclampsia

ANS: D Patients with placenta previa are not especially high risk for placental abruption. Patients colonized with group B streptococci are not especially high risk for placental abruption. Patients who are hepatitis B surface antigen positive are not especially high risk for placental abruption. Patients with eclampsia are high risk for placental abruption.

The perinatal nurse knows that the term to describe a woman at 26 weeks' gestation with a history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is: a. Preeclampsia b. Chronic hypertension c. Gestational hypertension d. Chronic hypertension with superimposed preeclampsia

ANS: D Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, and renal and central nervous systems. Chronic hypertension is hypertension that is present and observable prior to pregnancy or hypertension that is diagnosed before the 20th week of gestation. Gestational hypertension is a nonspecific term used to describe the woman who has a blood pressure elevation detected for the first time during pregnancy, without proteinuria. The following criteria are necessary to establish a diagnosis of superimposed preeclampsia: hypertension and no proteinuria early in pregnancy (prior to 20 weeks' gestation) and new-onset proteinuria, a sudden increase in protein—urinary excretion of 0.3 g protein or more in a 24-hour specimen, or two dipstick test results of 2+ (100 mg/dL), with the values recorded at least 4 hours apart, with no evidence of urinary tract infection; a sudden increase in blood pressure in a woman whose blood pressure has been well controlled; thrombocytopenia (platelet count lower than 100,000/mmC); and an increase in the liver enzymes alanine transaminase (ALT) or aspartate transaminase (AST) to abnormal levels.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks' gestation in her first pregnancy. She is worried about having her baby "too soon," and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks contractions

ANS: D Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the end of the 36th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor. Term labor occurs after 37 weeks' gestation. There is no indication in this scenario that this is back labor. Braxton-Hicks contractions are regular contractions occurring after the third month of pregnancy. They may be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

The nurse is caring for a woman at 28 weeks' gestation with a history of preterm delivery. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis? a. Human relaxin levels b. Amniotic fluid levels c. Alpha-fetoprotein levels d. Fetal fibronectin levels

ANS: D Relaxin levels are rarely assessed. In addition, they are unrelated to the incidence of preterm labor. Amniotic fluid levels are not directly related to the incidence of preterm labor. Alpha-fetoprotein levels are not related to the incidence of preterm labor. A rise in the fetal fibronectin levels in cervical secretions has been associated with preterm labor.

According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia: a. Take the patient's blood pressure every 6 hours b. Encourage the patient to rest on her back c. Notify the physician of a urine output greater than 30 mL/hr d. Administer magnesium sulfate according to agency policy

ANS: D The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The blood pressure is taken every 1 hour or more frequently according to physician orders or institutional protocol. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a side-lying position to enhance uterine perfusion. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria and the physician must be notified. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion.

A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother? a. Serum potassium level increases b. Diarrhea c. Urticaria d. Complaints of nervousness

ANS: D The nurse would not expect to see a rise in the mother's serum potassium levels. The beta agonists are not associated with diarrhea. The beta agonists are not associated with urticaria. Complaints of nervousness are commonly made by women receiving subcutaneous beta agonists.

A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see? a. Postpartum hemorrhage b. Neonatal hyperglycemia c. Postpartum oliguria d. Neonatal macrosomia

ANS: D The patient is not especially high risk for a postpartum hemorrhage. The nurse would expect to see neonatal hypoglycemia, not hyperglycemia. The nurse would expect to see postpartum polyuria. The nurse would expect to see neonatal macrosomia.

The single most important risk factor for preterm birth includes: a. Uterine and cervical anomalies b. Infection c. Increased BMI d. Prior preterm birth

ANS: D The single most important factor is prior preterm birth with a reoccurrence rate of up to 40%.

The nurse working in a prenatal clinic is providing care to three primigravida patients. Which of the patient findings would the nurse highlight for the physician? a. 15 weeks, denies feeling fetal movement b. 20 weeks, fundal height at the umbilicus c. 25 weeks, complains of excess salivation d. 30 weeks, states that her vision is blurry

ANS: D This finding is normal. Quickening is usually felt between 16 and 20 weeks' gestation. This finding is normal. The fundal height at 20 weeks' gestation is usually at the level of the umbilicus. Excess salivation is a normal, albeit annoying, finding. Blurred vision is a sign of pregnancy-induced hypertension (PIH). This finding should be reported to the woman's health-care practitioner.

Which of the following statements is most appropriate for the nurse to say to a patient with a complete placenta previa? a. "During the second stage of labor you will need to bear down." b. "You should ambulate in the halls at least twice each day." c. "The doctor will likely induce your labor with oxytocin." d. "Please promptly report if you experience any bleeding or feel any back discomfort."

ANS: D This response is inappropriate. This patient will be delivered by cesarean section. This response is inappropriate. Patients with placenta previa are usually on bed rest. This response is inappropriate. This patient will be delivered by cesarean section. Labor often begins with back pain. Labor is contraindicated for a patient with complete placenta previa.