Antepartum Complications
A client with severe preeclampsia is receiving magnesium sulfate therapy. What is the priority nursing assessment as the nurse monitors this client's response to therapy? 1 Urine output 2 Respiratory rate 3 Deep tendon reflexes 4 Level of consciousness
Answer: 2 Respiratory depression occurs with toxic levels of magnesium sulfate; calcium gluconate should be readily available to counteract toxicity. Although the other assessments (urine output, deep tendon reflexes, and level of consciousness) are important, none is the priority.
Which clinical finding does the nurse expect when assessing a client with abruptio placentae? 1 Flaccid uterus 2 Painless bleeding 3 Boardlike abdomen 4 Bright red bleeding
Anser: 3 Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots. Painless bleeding is associated with placenta previa; abdominal pain and uterine tenderness occur with abruptio placentae. In abruptio placentae the bleeding is not bright red; usually it is a port wine color.
A client with a diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. Which precaution should the nurse institute? 1 Padding the side rails on the bed 2 Placing the call button next to the client 3 Having oxygen and a facemask available 4 Assigning a nursing assistant to stay with the client
Answer: 1 Padded side rails help prevent injury during the clonic-tonic phase of a seizure. The client must be protected from injury if there is a seizure. Although some clients experience an aura before a seizure, there is not enough time to use a call button and wait for help. Oxygen is useless during a seizure when the client is not breathing or is thrashing about. Assigning a staff member to stay with the client in anticipation of a seizure is impractical and unproductive.
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? 1 Insulin needs will increase during the second trimester. 2 Insulin needs will decrease during the second trimester. 3 Insulin needs will not change during the second trimester. 4 Insulin will be switched to an oral antidiabetic medication during the second trimester.
Answer: 1 The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status. Major hormonal changes result in decreased tolerance of glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Increasing levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements gradually increase from about 18 to 24 weeks of gestation to about 36 weeks' gestation. The use of oral antidiabetes agents is currently not recommended by the American Diabetes Association for use during pregnancy.
A primary healthcare provider suspects ectopic pregnancy in an adolescent and conducts further evaluation. Which signs and symptoms have led the provider to suspect ectopic pregnancy? Select all that apply. 1 Hypotension 2 Abdominal pain 3 Vaginal bleeding 4 Cervical abnormalities 5 Maternal systemic illness
Answer: 1, 2, 3 An adolescent girl with hypotension and abdominal pain may have an ectopic pregnancy that has ruptured, and emergency surgery may be indicated after prompt evaluation. When an adolescent girl experiences vaginal bleeding and abdominal pain, ectopic pregnancy must be ruled out. Cervical abnormalities and systemic maternal illness may lead to spontaneous abortion, but they do not signal ectopic pregnancy.
A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Visual disturbances
Answer: 1, 3, 5 Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Visual disturbances in severe preeclampsia are related to retinal edema. Constipation and vaginal bleeding are not related to preeclampsia.
A pregnant client has class II cardiac disease. To best plan the client's care, what does the nurse anticipate for the client? 1 May participate in as much activity as she desires 2 Should be hospitalized if there is evidence of cardiac decompensation 3 Will have to maintain bed rest for most of the day throughout her pregnancy 4 May have to consider a therapeutic abortion if there is evidence of cardiac decompensation
Answer: 2 Clients with cardiac disease should be taught the signs and symptoms of cardiac decompensation; if they occur, the client should stop the activity that precipitated them and notify the primary healthcare provider. Participating in as much activity as she desires is acceptable behavior for a client with class I cardiac disease. Maintaining bed rest is the treatment for a client with class III cardiac disease. Considering a therapeutic abortion is the recommendation for a client with class IV cardiac disease.
The primary healthcare provider diagnoses placenta previa in a primiparous client. What does this indicate to the nurse regarding the condition of the placenta? 1 Infarcted 2 Low-lying 3 Immaturely developed 4 Separating prematurely
Answer: 2 Implantation should occur in the upper third of the uterus; a low-lying placenta is termed placenta previa. Infarctions may appear on a placenta because of some interference with the blood supply; this is not related to its location within the uterus. Placenta previa indicates where the placenta is implanted and has no relationship to placental aging. Abruptio placentae, not placenta previa, is the premature separation of a normally implanted placenta.
A client at 6 weeks' gestation who has type 1 diabetes is attending the prenatal clinic for the first time. The nurse explains that during the first trimester insulin requirements may decrease for what reason? 1 Body metabolism is sluggish in the first trimester. 2 Morning sickness may result in decreased food intake. 3 Fetal requirements of glucose in this period are minimal. 4 Hormones of pregnancy increase the body's need for insulin.
Answer: 2 Morning sickness, a common occurrence during pregnancy, contributes to decreased food intake; the insulin dosage must be reduced to prevent hypoglycemia. The body's metabolism increases during pregnancy, because the needs of the fetus, as well as those of the mother, must be met. Rapid organogenesis requires large amounts of glucose. During the first trimester the blood glucose level is reduced and glycemic control is enhanced; glycemic control is more difficult to maintain later in the pregnancy.
After the removal of a hydatidiform mole, the nurse assesses the client's laboratory data during a follow-up visit. The nurse notes that a prolonged increase of the serum human chorionic gonadotropin (hCG) level is a danger sign. Which condition is this client at increased risk of developing? 1 Uterine rupture 2 Choriocarcinoma 3 Hyperemesis gravidarum 4 Disseminated intravascular coagulation (DIC)
Answer: 2 hCG increases shortly after the onset of pregnancy, peaks at the end of the second month, then decreases and is sustained at a lower level until the end of pregnancy; a continued increase indicates retained trophoblastic tissue and possible choriocarcinoma. Uterine rupture is characterized by persistent, localized abdominal pain; it does not have a higher incidence in women with hydatidiform mole. Hyperemesis gravidarum cannot occur after termination of a pregnancy. DIC is manifested by shock, bleeding, a low platelet count, and elevated prothrombin time and partial thromboplastin time; it does not have a higher incidence in women with hydatidiform mole.
After an incomplete abortion, a client tells the nurse that although her primary healthcare provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse? 1 "I don't think you should focus on this anymore." 2 "It's when the fetus dies but is retained in the uterus for at least 2 months." 3 "It's when the fetus is expelled but other parts of the pregnancy remain in the uterus." 4 "I think it's best for you to ask your primary healthcare provider for the answer to that question."
Answer: 3 A correct and simple definition answers the question and fulfills the client's need to know. Telling the client not to focus on the topic any more denies the client's right to know. The definition of a missed abortion is when the fetus dies but is retained in the uterus for at least 2 months. Telling the client to ask her primary healthcare provider for the answer is an abdication of the nurse's responsibility; the nurse can independently reinforce information and correct misconceptions.
A client who is at 12 weeks' gestation tells the nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. Which factor is frequently associated with this disorder? 1 History of cholecystitis 2 Large amount of amniotic fluid 3 High level of chorionic gonadotropin 4 Decreased secretion of hydrochloric acid
Answer: 3 A high level of chorionic gonadotropin is frequently associated with severe vomiting during pregnancy and may result in hyperemesis gravidarum. A high level may also occur in the presence of a hydatidiform mole or multiple pregnancy. Cholecystitis is unrelated to this problem. Hydramnios (excessive amniotic fluid) is associated with multiple gestations and some fetal abnormalities. There are no data to indicate that there is decreased gastric acid secretion during the first trimester, and this is not the cause of hyperemesis gravidarum.
What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia? 1 Limiting IV fluid intake 2 Preparing for a possible precipitous birth 3 Maintaining a quiet, darkened environment 4 Obtaining magnesium gluconate as an antagonist
Answer: 3 A quiet, darkened room reduces stimuli, which is essential for limiting or preventing seizures. IV infusions are not limited. Infusions are monitored closely and usually maintained at a volume of 125 mL/hr. Precipitous birth is not a usual side effect of magnesium therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be kept on hand in case signs of toxicity appear.
The nurse is assessing a client with worsening preeclampsia. What is the most significant clinical manifestation of severe preeclampsia? 1 Polyuria 2 Vaginal spotting 3 Proteinuria of 3+ 4 Blood pressure of 130/80 mm Hg
Answer: 3 As preeclampsia worsens, blood pressure and edema increase and degenerative changes of the kidney cause increasing proteinuria (3+). With worsening preeclampsia, oliguria, not polyuria, is expected. Vaginal spotting is not a sign of worsening preeclampsia. A blood pressure of 130/80 mm Hg is within acceptable limits; however, there is insufficient information to determine whether it is increased in this client.
A primigravida client with type 1 diabetes is attending her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur? 1 Tenth and twelfth weeks of gestation 2 Eighteenth and twenty-second weeks of gestation 3 Twenty-fourth and twenty-eighth weeks of gestation 4 Thirty-sixth and fortieth weeks of gestation
Answer: 3 At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases, and insulin needs decrease accordingly.
Which nursing intervention is specific to clients in active labor who present with a history of cardiac disease? 1 Encouraging frequent voiding 2 Checking the blood pressure hourly 3 Auscultating the lungs for crackles every 30 minutes 4 Helping turn the client from side to side at 15-minute intervals
Answer: 3 Clients with cardiac problems are prone to heart failure during active labor; crackles indicate the presence of pulmonary edema. Encouraging frequent voiding and checking the blood pressure hourly is done for all clients who are in labor. Helping turn the client from side to side at 15-minute intervals is not necessary; although clients who are in labor are maintained on the side to facilitate venous return, the sides do not have to be alternated every 15 minutes.
The nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate? 1 Hypotension 2 Decreased fetal heart rate 3 Unusual uterine enlargement 4 Painless, heavy vaginal bleeding
Answer: 3 The proliferation of trophoblastic tissue filled with fluid causes the uterus to enlarge more quickly than if a fetus were in the uterus. Hypertension, not hypotension, often occurs with a molar pregnancy. There is no fetus within a hydatidiform mole. There may be slight painless vaginal bleeding.
A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. What does the nurse identify as the main reason that this medication is administered? 1 It acts as a diuretic. 2 It has a sedative effect. 3 It acts as an anticonvulsant. 4 It has an antihypertensive effect.
Answer: 3 The target tissue of magnesium sulfate is the myoneural junction; it decreases secretion of acetylcholine, thereby depressing neuromuscular transmission, which prevents seizures. Although diuresis occurs, this is not the purpose of giving magnesium sulfate. Magnesium sulfate does not have a sedative effect. It has a minimum hypotensive effect.
A client who is at risk for seizures as a result of severe preeclampsia is receiving an intravenous infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. 1 Proteinuria 2 Epigastric pain 3 Respirations of 10 breaths/min 4 Loss of patellar reflexes
Answer: 3, 4 A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia. Magnesium sulfate toxicity is not accompanied by proteinuria; proteinuria is a sign of preeclampsia. Epigastric pain is associated with severe eclampsia, not magnesium sulfate toxicity. Urine output of 40 mL/hr is an acceptable output; an output of less than 30 mL/hr may contribute to the development of a toxic level of magnesium.
Which statements by a client with hyperemesis gravidarum would confirm that the client requires further teaching? Select all that apply. 1 "I'll start drinking protein shakes." 2 "I'll start drinking plenty of fluids." 3 "I'll start limiting my carbohydrates." 4 "I'll lie down for at least 2 hours after I eat." 5 "I'll be sure to schedule rest periods throughout the day so I won't get tired."
Answer: 3, 4 During pregnancy the cardiac sphincter may relax, which allows food to come back up into esophagus when supine. Not lying down for up to 2 hours after eating should provide time for digestion so that food is not regurgitated. The client should not decrease carbohydrate intake. Hyperemesis gravidarum can be aggravated by stress and fatigue. Rest periods may reduce the client's stress level and fatigue and promote relaxation. The client should be encouraged to drink plenty of fluids to help prevent dehydration. Drinking protein shakes can help provide protein needed to decrease the chance of a negative nitrogen balance.
A few hours after being admitted to the hospital with a diagnosis of inevitable abortion, a client at 16 weeks' gestation begins to experience a bearing-down sensation and suddenly expels the products of conception in the bed. What should the nurse do first? 1 Notify the primary healthcare provider 2 Administer the prescribed sedative 3 Take the client to the operating room 4 Check the client's fundus for firmness
Answer: 4 After a spontaneous abortion the uterine fundus should be palpated for firmness, which indicates effective uterine tone. If the uterus is not firm or appears to be hypotonic, hemorrhage may occur; a soft or boggy uterus also may indicate retained placental tissue. The nurse would notify the primary healthcare provider if necessary after checking for fundal firmness. Administering the prescribed sedative is not the priority; the potential for hemorrhage must be monitored. Taking the client to the operating room is unnecessary; fetal and placental contents are small and expelled easily.
A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. Which characteristic typical of placenta previa supports the nurse's conclusion? 1 Painful vaginal bleeding in the first trimester 2 Painful vaginal bleeding in the third trimester 3 Painless vaginal bleeding in the first trimester 4 Painless vaginal bleeding in the third trimester
Answer: 4 As the lower uterine segment stretches and thins, painless tearing and bleeding occur at the low implantation site. First-trimester bleeding, painful or painless, is associated with spontaneous abortion or inadequate implantation, not placenta previa. Painful vaginal bleeding in the third trimester is usually associated with abruptio placentae rather than placenta previa.
What should the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? 1 Bed rest with sedation 2 Trendelenburg position and hydration 3 Preparation for emergency cesarean birth 4 External fetal monitoring and oxygenation
Answer: 4 Fetal monitoring and oxygen administration should be instituted to protect the fetus. Some placental separation has occurred, and it may progress further. Sedation is contraindicated; it may further stress an already compromised fetus. The Trendelenburg position may shift the heavy uterus against the diaphragm and lead to compromised maternal respiratory function, further depriving the fetus of oxygen. Hydration is not a priority at this time. Further assessment of fetal status and progression of abruption placentae is needed before a cesarean birth is considered.
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect both diet and insulin needs. How should the nurse respond? 1 "Insulin needs will decrease; the excess glucose will be used for fetal growth." 2 "Diet and insulin needs won't change, and maternal and fetal needs will be met." 3 "Protein needs will increase, and adjustments to insulin dosage will be necessary." 4 "Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."
Answer: 4 Insulin requirements may decrease in early pregnancy because of increased fetal needs for nutrients and the possibility of maternal nausea and vomiting. Insulin requirements increase in the second and third trimesters as resistance to insulin develops. The blood glucose level is monitored to prevent ketoacidosis and harm to both the mother and fetus. Telling the client that protein needs will increase and adjustments to the insulin dosage will be necessary conveys information that is true only during early pregnancy. Even the nondiabetic woman makes dietary adjustments necessary to keep pace with the increased nutritional demands of pregnancy; in addition, insulin requirements increase in the second and third trimesters. Most nutrient requirements, not just protein, increase during pregnancy.