MNB Chapter 17
A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse? "Your spontaneous bleeding is not work-related." "It is hard to know why a woman bleeds during early pregnancy." "Something was wrong with the fetus." "I can understand your need to find an answer to what caused this. Let's talk about this further."
"I can understand your need to find an answer to what caused this. Let's talk about this further." Explanation: Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.
After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful? "I will be sure to avoid getting pregnant for at least 1 year." "My blood pressure will continue to be increased for about 6 more months." "My intake of iron will have to be closely monitored for 6 months." "I won't use my birth control pills for at least a year or two."
"I will be sure to avoid getting pregnant for at least 1 year." Explanation: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.
A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective? "The cervix is glued shut so no amniotic fluid can escape." "Purse-string sutures are placed in the cervix to prevent it from dilating." "Staples are put in the cervix to prevent it from dilating." "A cervical cap is placed so no amniotic fluid can escape."
"Purse-string sutures are placed in the cervix to prevent it from dilating." Explanation: The cerclage, or purse string suture is inserted into the cervix to prevent preterm cervical dilatation and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.
A pregnant client at 32 weeks' gestation is treated with magnesium sulfate for seizure management. The nurse assesses which of the following for evidence of magnesium toxicity? Absence of knee jerk response Increased blood pressure Increased rate of respiration Frequency of micturition
Absence of knee jerk response Explanation: Magnesium sulfate toxicity is characterized by absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, and not frequency of micturition, is seen with magnesium sulfate toxicity. Magnesium sulfate is given to treat seizures associated with hypertension and proteinuria in pregnancy, and therefore decreases the blood pressure. It does not cause an increase in blood pressure. There is respiratory depression, and not an increased rate of respiration, with magnesium sulfate toxicity.
A pregnant patient is diagnosed with placenta previa. Which action should the nurse implement immediately for this patient? Prepare for a vaginal examination to assess the extent of bleeding. Assess uterine contractions by an internal pressure gauge. Help the patient remain ambulatory to reduce bleeding. Assess fetal heart sounds with an external monitor.
Assess fetal heart sounds with an external monitor. Explanation: For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine contractions are contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both mother and child. To ensure an adequate blood supply to the patient and fetus, the patient should be placed immediately on bed rest in a side-lying position.
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first? Administer oxygen to the client. Provide emotional support to the client and significant other. Obtain a surgical consent from the client. Assess the client's vital signs.
Assess the client's vital signs. Explanation: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.
What special interventions would the nurse implement in a client who is carrying twin fetuses? Schedule non-stress tests (NST) starting at 16 weeks. Remind the client to monitor her intake since she does not need any more food for a multiple pregnancy than she would ingest for a singleton pregnancy. Assist the physician on doing uterine ultrasounds every 2 weeks to monitor fetal size and placental information. Demonstrate to the client how to perform fetal movement counts after 32 weeks.
Demonstrate to the client how to perform fetal movement counts after 32 weeks. Explanation: A woman carrying a multiple gestation needs to keep up with how her fetuses are doing, and an excellent way to do that is by doing fetal movement counts, or "kick counts" as they are sometimes called. This starts at around 32 weeks' gestation for an uncomplicated pregnancy and continues until delivery. Weekly or bi-weekly NSTs begin after 32 weeks. Obstetrical ultrasounds are done every 4 to 6 weeks after confirmation of a multiple fetal pregnancy. The client needs to increase her intake, along with her iron and folic acid intake, to provide adequate nutrition for both fetuses.
A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia? Monitor the client for headaches or swelling on the body. Have her blood pressure checked at every prenatal visit. Take low-dose antihypertensive prophylactically. Take one aspirin every day.
Have her blood pressure checked at every prenatal visit. Explanation: Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention— nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.
A patient is admitted with a diagnosis of ectopic pregnancy. For what should the nurse anticipate preparing the patient? Immediate surgery Intravenous administration of a tocolytic Bed rest for the next 4 weeks Internal uterine monitoring
Immediate surgery Explanation: An ectopic pregnancy is one in which implantation occurred outside the uterine cavity, usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The patient does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the patient is not in labor.
A patient recovering from an uneventful vaginal delivery is prescribed Rho(D) immune globulin (RhIG). What should the nurse explain to the patient regarding the purpose of this medication? It stimulates maternal D immune antigens. It promotes maternal D antibody formation. It prevents fetal Rh blood formation. It prevents maternal D antibody formation.
It prevents maternal D antibody formation. Explanation: Rho(D) immune globulin (RhIG) is given to Rh-negative pregnant patients to prevent the formation of maternal antibodies to the Rh-positive blood type of the developing fetus. This medication does not prevent fetal Rh blood formation, stimulate maternal immune antigens, or promote maternal antibody formation.
A pregnant patient is developing HELLP syndrome. During labor, which order should the nurse question? Assess blood pressure every 15 minutes. Prepare for epidural anesthesia. Position on the left side during labor. Assess urine output every hour.
Prepare for epidural anesthesia. Explanation: In the HELLP syndrome, patients develop low platelet counts. With a low platelet count, injections such as epidural anesthesia are contraindicated. This is the order that the nurse should question. The patient's urine output should be assessed every hour because renal failure is a complication of this syndrome. Positioning on the left side during labor will help blood flow to the uterus. Assessing blood pressure every 15 minutes is appropriate for the patient with this syndrome.
The nurse is caring for a client who has a multifetal pregnancy. What topic should the nurse prioritize during health education? Risk for blood incompatibilities Risk for hypertension Parenting skills Signs of preterm labor
Signs of preterm labor Explanation: The client with a multifetal pregnancy must be made aware of the risks posed by preterm labor. There is no corresponding increase in the risk for hypertension or blood incompatabilities. Parenting skills are secondary to physiologic needs at this point.
A pregnant patient with a history of premature cervical dilatation undergoes cervical cerclage. Which outcome indicates that this procedure has been successful? The client delivers a full-term fetus at 39 weeks' gestation. The client experiences minimal vaginal bleeding throughout the pregnancy. The client has reduced shortness of breath and abdominal pain during the pregnancy. The client's membranes spontaneously rupture at week 30 of gestation.
The client delivers a full-term fetus at 39 weeks' gestation. Explanation: Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a fetus until term. After the loss of one child because of premature cervical dilatation, a surgical operation termed cervical cerclage can be performed to prevent this from happening in a second pregnancy. This procedure is the use of purse-string sutures placed in the cervix to strengthen the cervix and prevent it from dilating until the end of pregnancy. Evidence that this procedure is effective would be the client delivering a full-term fetus at 39 weeks' gestation. Spontaneous rupture of the membranes could indicate that the procedure was not successful. Vaginal bleeding could indicate another health problem or that the procedure was not successful. This procedure does not impact the patient's respirations or amount of abdominal pain while pregnant. These manifestations could indicate another health problem with the pregnancy.
A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for? Twin-to-twin transfusion syndrome (TTTS) ABO incompatibility TORCH syndrome HELLP syndrome
Twin-to-twin transfusion syndrome (TTTS) Explanation: When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission? assessing fetal heart tones by use of an external monitor performing a vaginal examination to assess the extent of bleeding helping the woman remain ambulatory to reduce bleeding assessing uterine contractions by an internal pressure gauge
assessing fetal heart tones by use of an external monitor Explanation: Not disrupting the placenta is a prime responsibility. An internal monitor, a vaginal examination, and remaining ambulatory could all do this and thus are contraindicated.
It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time? 24 hours before birth and 24 hours after birth at 28 weeks' gestation and again within 72 hours after birth at 32 weeks' gestation and immediately before discharge in the first trimester and within 2 hours of birth
at 28 weeks' gestation and again within 72 hours after birth Explanation: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.
Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? calcium carbonate potassium chloride calcium gluconate ferrous sulfate
calcium gluconate Explanation: The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? elevated liver enzymes elevated platelet count hyperglycemia disseminated intravascular coagulopathy (DIC)
elevated liver enzymes Explanation: HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia is not a part of this syndrome. HELLP may increase the woman's risk for DIC.
A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect? ensures passage of all the products of conception alleviates strong uterine cramping halts the progression of the abortion suppresses the immune response to prevent isoimmunization
ensures passage of all the products of conception Explanation: Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an abortion to ensure passage of all the products of conception. Rho(D) immune globulin is used to suppress the immune response and prevent isoimmunization.
Which medication would the nurse prepare to administer if prescribed as treatment for an unruptured ectopic pregnancy? promethazine oxytocin methotrexate ondansetron
methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.