Ch. 10 - Complications of pregnancy.
Which interventions may be indicated for the clinical management of hyperemesis gravidarum (HEG). Select all a. pyridoxine b. total parenteral nutrition TPN for severe cases c. Promethazine (Phenergan) d. Levaquin (Levofloxacin) e. Omeprazole (Prilosec) f. diphenhydramine (Benadryl)
A, B, C, E, F An antibiotic such as Levaquin is not indicated for the treatment of this disease
For the client who delivered at 6:30am on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to a. 6:30 am on Jan 13 b. 6:30 pm on Jan 13 c. 6:30 pm on Jan 14 d. 6:30 am on Jan 15
a. 6:30 am on Jan 13 rationale: Rho(D) immune globulin (RhoGAM) must be administered within 72 hours after the birth of an Rh-positive infant.
A female client presents to the ED complaining of lower abdominal cramping with scant bleeding of approximately 2 days duration. This morning, the quality and location of the pain changed and she is now experiencing pain in her shoulder. The clients last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days. Which clinical diagnosis does the nurse suspect. a. Ectopic pregnancy b. appendicitis c. food poisoning d. gastroenteritis
a. Ectopic pregnancy rationale: Even though the clients menstraul cycle has variability, all women are considered to be pregnant until proven otherwise.
The clinic nurse is reviewing home care dietary instructions for the patient diagnosed with mild preeclampsia at 34 weeks gestation. The nurse determines that the client requires additional information when she makes which statement. a. I will limit my salt intake to 2 grams per day b. I will drink no less than 2500 mL of fluid per day c. I will make sure I eat 4 sources of protein per day d. my overall intake of calories per day should be around 2500
a. I will limit salt intake to 2 grams per day rationale: the diet should have ample protein, no less than 6 oz/day, and approximately 2500 calories during the second half of pregnancy.
Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome a. Abdominal palpation b. venous sample of blood c. checking deep tendon reflexes d. auscultation of the heart and lungs.
a. abdominal palpation rationale: palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subscapular hematoma.
A laboratory finding indicative of DIC is a. decreased fibrinogen b. increased platelets c. increased hematocrit d. decreased thromboplastin time
a. decreased fibrinogen rationale: DIC develops when the blood clotting factor thromboplastin is released into the maternal bloodstream as a result of placental bleeding.
Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa. a. Determining cervical dilation and effacement b. Monitoring FHR and maternal vital signs c. Observing vaginal bleeding of leakage of amniotic fluid. d. determining frequency, duration, and intensity of contractions
a. determining cervical dilation and effacement rationale: Vaginal exam of the cervix may result in perforation of the placenta and subsequent hemorrhage.
A 32 year old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following. a. Hemorrhage is the major concern b. she will be unable to conceive in the future. c. bed rest and analgesics are the recommended treatment. d. A D&C will be performed to remove the products of conception
a. hemorrhage is the major concern rationale: severe bleeding occurs if the fallopian tube ruptures.
As the triage nurse in the ED, you are reviewing results for the high risk obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident. You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that: a. immediate birth is required. b. the client should be transferred to the critical care unit for closer observation c. RhoGAM should be administered d. a tetanus shot should be administered
a. immediate birth is required rationale: A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and because the client is a trauma victim, it is highly likely that she is experiencing an abruption
The physician suspects that the client may have gestational trophoblastic disease. Which clinical manifestations support this diagnosis. select all a. Increased levels of beta-hCG in the serum b. Fundal height correlating with reported gestational age c. Vaginal bleeding d. Vomiting e. Maternal hypotension
a. increased levels of beta-hCG in the serum c. vaginal bleeding d. vomiting rationale: clinical manifestations include: increased levels of beta-hCG, increased size of the uterus related to gestational age, nausea and vomiting, and evidence of vaginal bleeding.
A patient reports to the ED nurse that she is 10 weeks pregnant, with unilateral pelvic pain, shoulder pain, and faintness. Her color is pale, she is diaphoretic, and her heart rate is 140 bpm. What is the nurses priority action a. Initiate an ordered IV of lactated Ringers at 200 ml/hr b. take the patient for her ordered pelvic ultrasound c. Ask the patient if she has had any recent vaginal bleeding d. ask the patient if she has ever been told she has had salpingitis
a. initiate an ordered IV of lactated Ringers at 200 ml/hr rationale: this patient is presenting with classic signs of an ectopic pregnancy and hypovolemic shock. This is an obstetric emergency. Symptoms include sudden, severe pain in one of the lower quadrants of the abdomen as the tube tears open and the embryo is expelled into the pelvic cavity, often with profuse abdominal hemorrhage.
The ED charge nurse calls the labor and birth charge nurse and reports the ambulance is en route with a seizing pregnant patient at 36 weeks gestation. What medication will the charge nurse most likely direct the staff nurse to prepare to administer immediately on the patients arrival to the labor and birth unit a. Magnesium sulfate (magnesium) b. Hydralazine (Apresoline) c. Carbamazepine (Tegretol) d. Terbutaline (Brethine)
a. magnesium sulfate (magnesium) rationale: mag sulfate is the drug most often used for preeclamptic and eclamptic patients.
the nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for which symptoms. select all a. pelvic pain b. missed period c. abdominal pain d. unanticipated heaving bleeding e. vaginal spotting or light bleeding
a. pelvic pain b. missed period c. abdominal pain e. vaginal spotting or light bleeding
A high risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via c-section. Which finding in the immediate post-operative period indicates that the client is at risk of developing HELLP syndrome a. Platelet count of 50,000/mL b. liver enzyme levels within normal range c. negative for edema d. no evidence of nausea or vomiting
a. platelet count of 50,000.mL rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels, and a low platelet count. A platelet count of 50,000/mL indicates thrombocytopenia
Spontaneous termination of a pregnancy is considered to be an abortion if a. the pregnancy is less than 20 weeks b. the fetus weighs less than 1000g c. the products of conception are passed intact d. there is no evidence of intrauterine infection
a. the pregnancy is less than 20 weeks. rationale: an abortion is the termination of pregnancy before the age of viability.
What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks gestation presenting with abdominal pain and bleeding a. Treated 1 yr ago for pelvic inflammatory disease (PID) b. oral contraception for last 3 years c. Urinary frequency for 1 week d. Irregular cycles for 1 year prior to conception
a. treated 1 yr ago for pelvic inflammatory disease (PID) rationale: PID causes fallopian tube damage. Blockage of the tube prevents movement of the fertilized ovum, resulting in implantation in the tube.
Which finding should be the nurses priority in a client suspected as having gestational trophoblastic disease a. Uterine contractions b. nausea and vomiting c. blood pressure of 130/80 mm Hg d. Increase discharge of vaginal mucus.
a. uterine contractions rationale: uterine contractions can cause trophoblastic tissue to be pulled into large venous sinusoids in the uterus, resulting in embolization of the tissue and respiratory distress.
A client who was pregnant had a spontaneous abortion at approximately 4 weeks gestation. At the time of miscarriage, it was thought that all products of conception were expelled. Two weeks later, the client presents at the clinic office complaining of "crampy" abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temp of 100º with BP of 100/60, irregular pulse 88 bpm. Based on these assessment data, what does the nurse anticipate as a clinical diagnosis. a. Ectopic pregnancy b. Uterine infection c. Gestational trophoblastic disease d. endometriosis.
b. Uterine infection rationale: the client is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and blood pressure and pulse manifesting as shock-trended vitals.
Which assessment finding suggests that your laboring clients blood magnesium level is too high a. Hyperactive reflexes b. absent reflexes c. Generalized seizure d. Urine output of 60 mL/hr
b. absent reflexes rationale: Magnesium acts as a central nervous system depressant by blocking neuromuscular transmission. Assessment of the deep tendon reflexes in an indication of the level of CNS depression. Absent reflexes indicates magnesium toxicity.
Which intervention would be the most effective if your client who is on magnesium sulfate has a RR of 10 breaths/min a. Give oxygen by mask at 8-10L/min b. Administer calcium gluconate via IV pyelogram (IVP) c. arouse client with tactile stimulation d. Continually assess pulse oximeter levels
b. administer calcium gluconate via IV pyelogram (IVP) rationale: A RR of less than 12 breaths/min in a client receiving magnesium sulfate is a sign of magnesium toxicity, which must be immediately reversed.
A client taking magnesium sulfate has a respiratory rate of 10 bpm. In addition to discontinuing the medication, which action should the nurse take. a. increase the clients IV fluids b. administer calcium gluconate c. vigorously stimulate the client. d. instruct the client to take deep breaths.
b. administer calcium gluconate. rationale: Calcium gluconate reverses the effects of magnesium sulfate.
Which of these interventions should the nurse recognize as the priority for the client diagnosed with an intact tubal pregnancy a. Assessment of pain level b. administration of methotrexate c. administration of Rh immune globulin d. Explanation of the common side effects of the treatment plan
b. administration of methotrexate rationale: the goal of medical management of an intact tube is to preserve the tube and improve the chance of future fertility.
The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for. select all a. cool, clammy skin b. altered sensorium c. pulse oximeter reading of 95% d. respiratory rate of less than 12 e. absence of deep tendon reflexes
b. altered sensorium d. RR of less than 12 e. absence of deep tendon reflexes Signs of magnesium toxicity include the following: RR < 14 SpO2 < 95% absent deep tendon reflexes sweating, flushing altered sensorium hypotension serum mag above 4 to 8 mg/dL
The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to a. monitor uterine contractions b. assess fetal heart rate and maternal vital signs c. place clean disposable pads to collect any drainage d. perform a venipuncture for hemoglobin and hematocrit levels.
b. assess fetal heart rate and maternal vital signs. rationale: assessment of the fetal heart rate and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus.
A labor and birth nurse receives a call from the lab regarding preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patients magnesium level is 7.6 mg/dL. What is the nurses priority action a. Stop the infusion of magnesium b. Assess the patients respiratory rate c. assess the patients deep tendon reflexes d. Notify the HCP of the magnesium
b. assess the patients respiratory rate rationale: the therapeutic serum level for magnesium is 4 to 8 mg/dl although it is elevated in terms of normal lab values.
Which is the only known cure for preeclampsia a. Magnesium sulfate b. delivery of the fetus c. antihypertensive medications d. administration of aspirin (ASA) every day of the pregnancy.
b. delivery of the fetus rationale: if the fetus is viable and near term, birth is the only known cure for preeclampsia.
Rh incompatibility can occur if the client is Rh-negative and the a. fetus is Rh-negative b. fetus is Rh-positive c. father is Rh positive d. father and fetus are both Rh-negative.
b. fetus is Rh-positive. rationale: For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive.
Which information should the labor nurse recognize as being pertinent to a possible diagnosis of abruptio placentae a. Low back pain b. Firm, tender uterus c. Regular uterine contractions d. scant vaginal mucus drainage.
b. firm, tender uterus rationale: A firm, tender uterus is a classic sign of abruptio placentae; low back pain, regular uterine contractions, and scant vaginal mucus drainage are normal findings in a laboring client
Which finding could cause the nurse to suspect gestational trophoblastic disease in a client at 8 weeks gestation. a. blood pressure of 128/70 mm Hg b. fundal height of 12 cm c. nausea and vomiting d. weight gain of 3 pounds
b. fundal height of 12 cm rationale: gestational trophoblastic disease is characterized by proliferation and edema of the chorionic villi. The fluid-filled form grapelike clusters of tissue that can rapidly grow to fill the uterus to the size of a more advanced pregnancy.
Which would indicate concealed hemorrhage in abruptio placentae a. bradycardia. b. hard boardlike abdomen c. decrease in fundal height d. decrease in abdominal pain.
b. hard board-like abdomen. rationale: concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, board-like abdomen.
A client is admitted with vaginal bleeding at approximately 10 weeks gestation. Her fundal height is 13cm. Which potential problem should be investigated. a. Placenta previa b. hydatidiform mole c. Abruptio placentae d. disseminated intravascular coagulation.
b. hydatidiform mole rationale: gestational trophoblastic disease (hydatidiform) is usually detected in the first trimester. The frequency of this condition is highest at both ends of a womans reproductive life.
An abortion when the fetus dies but is retained in the uterus is called a. inevitable b. missed c. incomplete d. threatened
b. missed rationale: a missed abortion refers to a dead fetus being retained in the uterus.
Which orders should the nurse expect for a client admitted with a threatened abortion. a. NPO b. Pad count c. ritodrine IV d. Meperidine (demerol) 50 mg now.
b. pad count rationale: A client admitted with a threatened abortion should be instructed to count the number of pads used and to note the quantity and color of blood on the pads.
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae a. Saturated perineal pad in 1 hour b. pain level 0 on a scale of 0 - 10 c. Cervical dilation at 2 cm d. fetal heart rate at 160 bpm
b. pain level 0 on a scale of 0-10 rationale: the classic sign of placenta previa is the sudden onset of painless uterine bleeding, whereas abruptio placentae results in abdominal pain and uterine tenderness; heavy bleeding, cervical dilation, and fetal heart rate of 160 bpm could be associated with both conditions
Which data found on a clients health history would place her at risk for an ectopic pregnancy. a. Ovarian cyst 2 years ago b. recurrent pelvic infections c. use of oral contraceptives for 5 years d. heavy menstrual flow of 4 days duration
b. recurrent pelvic infections rationale: infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for implantation.
Which assessment finding indicates an adverse response to magnesium sulfate. a. Urine output of 30mL/hr b. respiratory rate of 11 bpm c. hypoactive patellar reflex d. blood pressure reading of 110/80 mm Hg.
b. respiratory rate of 11 bpm rationale: a respiratory rate less than 12 bpm indicates magnesium toxicity and requires immediate intervention.
A HCP reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurses priority action when the patient is admitted a. Obtain the patients weight b. take the patients vital signs c. start an IV with lactated Ringers at 75 mL/hr d. ask support persons to leave the birthing room
b. take the patients vital signs rationale: the hallmark signs of preeclampsia are hypertension and proteinuria.
Which explanation of a marginal placenta previa would the nurse provide to her client a. The placenta is in the lower uterus, completely covering the internal cervical os b. The placenta is in the lower uterus, more than 3 cm from the internal cervical os c. The placenta is in the lower uterus, less than 3 cm from the internal cervical os d. The placenta is in the lower uterus, at the edge and partially covering the cervical os.
b. the placenta is in the lower uterus, more than 3 cm from the internal cervical os. rationale: A marginal placenta, also called a low-lying placenta, is more than 3 cm from the internal cervical os.
Which maternal condition always necessitates birth by cesarean section. a. partial abruptio placentae b. total placenta previa. c. ectopic pregnancy. d. eclampsia.
b. total placenta previa. in total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal birth occurred.
A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area. a. +1 b. +2 c. +3 d. +4
c. +3 rationale: edema of the extremities, face, and sacral area is classified as +3 edema.
A preeclamptic patient is receiving an IV infusion of magnesium sulfate. On assessment, the nurse notes that the patients urinary output has been 20 mL/hr for the past 2 hours and her deep tendon reflexes are absent. The HCP prescribes calcium gluconate, 1 g of a 10% solution. The standard rate of infusion is 1 mL/min. How many minutes will it take for the nurse to administer the prescribed calcium a. 1 b. 5 c. 10 d. 15
c. 10 rationale: a 10% solution contains 10 g in 100 mL
A blood soaked peripad weighs 900 g. the nurse would document a blood loss of ________ a. 1800 b. 450 c. 900 d. 90
c. 900 rationale: One G = 1mL of blood.
A patient presents to labor and birth with complaints of persistent acute back pain at 36 weeks gestation. The nursing assessment reveals a taught abdomen, fundal height at 40 cm, and late decelerations, with an FHR range of 124 to 128 bpm. The nurse will implement the protocol for which obstetric condition a. Placenta previa b. Hypovolemic shock c. abruptio placentae or abruption d. DIC
c. abruptio placentae of abruption rationale: there are five classic signs and symptoms of abruptio placentae and include the following: bleeding, uterine tenderness, uterine irritability, abdominal or low back pain, an high uterine resting tone
A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a. diuretic b. tocolytic c. anticonvulsant d. antihypertensive.
c. anticonvulsant rationale: anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity.
The most appropriate nursing action for the client complaining of continuous headache 24 hours postpartum after a normal vaginal birth is to a. encourage bed rest b. administer analgesic c. assess blood pressure d. assess for pitting edema
c. assess blood pressure rationale: the first indication of preeclampsia is usually hypertension. Continuous headache indicates poor cerebral perfusion and may be a precursor of seizures; encouraging bed rest, administering an analgesic, and assessing for edema are not interventions to determine the source of the clients headache.
a 17 yr old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to a. advise her to cut down on fast foods that are high in fat b. caution her to avoid salty foods and to return in 2 weeks c. assess weight gain, location of edema, and urine for protein. d. recommend she stay home from school for a few days to reduce stress.
c. assess weight gain, location of edema, and urine for protein. rationale: the nurse should further assess the client for hypertension, generalized edema, and proteinuria, which are classic signs of pregnancy induced hypertension.
You are taking care of a client who had a therapeutic abortion following an episode of vaginal bleeding and ultrasound confirmation of a blighted ovum. Lab work is ordered 2 weeks post procedure as a follow up. Which result indicates the additional intervention is needed. a. Hemoglobin, 13.2 mg/dL b. white blood cell count 10,000 mm3 c. Beta-hCG detected in serum d. fasting blood glucose level 80 mg/dL
c. beta-hcg detected in serum rationale: the presence of beta-hcg in serum 2 weeks after the procedure is clinically significant and indicates the possibility that there may have been a molar pregnancy (hydatidiform).
Which finding in the assessment of a client following an abruption placenta could indicate a major complication a. urine output of 30 ml in 1 hour b. blood pressure of 110/60 mm Hg c. Bleeding at IV insertion site d. Respiratory rate of 16 breath/min
c. bleeding at IV insertion site rationale: DIC is a life threatening defect in coagulation that may occur following abruptio placentae
Which finding in the exam of a client with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion a. Presence of backache b. ris in hCG level c. clear fluid from vagina d. pelvic pressure
c. clear fluid from vagina rationale: clear fluid from the vagina indicates rupture of the membranes.
In addition to obtaining vital signs and FHT, what is a priority for the client with placenta previa. a. Determining cervical dilation b. monitoring uterine contractions c. estimating blood loss d. starting a pitocin drip
c. estimating blood loss rationale: nursing assessments for the client with placenta previa focus on determining the amount of blood loss.
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole a. blood pressure of 120/80 mm Hg b. complaint of frequent mild nausea c. Fundal height measurement of 18cm d. history of bright red spotting for 1 day weeks ago.
c. fundal height measurement of 18 cm. rationale: the uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy.
The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia. a. Edema b. proteinuria c. glucosuria d. hyptertension
c. glucosuria rationale: glucose into the urine is not one of the three classic symptoms of preeclampsia.
Fraternal twins are delivered by your Rh-negative client. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the a. direct coombs test of twin A b. direct coombs test of twin B c. indirect Coombs test of the mother d. transcutaneous bilirubin level for both twins
c. indirect Combs test of the mother rationale: administration of RhoGAM is based on the results of the indirect Coombs test on the client
What is the priority nursing intervention for the client who has had an incomplete abortion. a. Methylergonovine (Methergine), 0.2 mg IM b. Preoperative teaching for surgery c. insertion of IV line for fluid replacement d. Positioning of client in left side lying position
c. insertion of IV line for fluid replacement. rationale: initial treatment of an incomplete abortion should be focused on stabilizing the clients cardiovascular state.
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa. a. Female fetus, Mexican American primigravida b. male fetus, Asian American, previous preterm birth c. Male fetus, African American, previous C-section d. Female fetus, European-American, previous spontaneous abortion
c. male fetus, African American, previous C section rationale: the rate of placenta previa is increasing. It is more common in older women, multiparous women, women who have had c-sections, and women who had suction curettage for an induced or spontaneous abortion.
Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication a. drowsiness b. urinary output of 20 mL/hr c. normal deep tendon reflexes d. Respiratory rate of 10 to 12 bmp
c. normal deep tendon reflexes rationale: magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability.
The primary symptom present in abruptio placentae that distinguishes it from placenta previa is: a. vaginal bleeding b. rupture of membranes c. presence of abdominal pain d. changes in maternal vital signs.
c. presence of abdominal pain rationale: Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus.
What should the nurse recognize as evidence that the client is recovering from preeclampsia. a. 1+ protein b. 2+ pitting edema in lower extremities c. urine output >100mL/hr d. Deep tendon reflexes +2
c. urine output >100mL/hr rationale: rapid reduction of the edema associated with preeclampsia results in urinary output of 4 to 6 L/day as interstitial fluids shift back to the circulatory system.
The nurse is providing care to a patient who just learned her baby has died in utero at 26 weeks gestation. What is the nurses next action a. Contact the patients clergy member b. enroll the patient in a grief and loss class c. Determine if the patient is a victim of violence d. Ask the patient when she last felt the baby move.
d. ask the patient when she last felt the baby move rationale: determining fetal movement will give the nurse a basis for how long the fetus has been expired.
the nurse is providing care to a laboring woman who is Rh-negative. The patient has a standing prescription to receive RhoGAM, if indicated. When will the nurse plan on administering the RhoGAM, if indicated a. Approximately 2 hours prior to birth b. At the birth of the placenta c. One hour after the birth of the infant d. between 48 and 72 hours after birth of the infant
d. between 48 and 72 hours after birth of the infant rationale: If the mother is Rh-negative, umbilical cord blood is taken at birth to determine blood type, Rh factor, and antibody titer (direct Coombs test) of the newborn. Rh-negative unsensitized mothers who give birth to Rh-positive infants are given an IM injection of Rho(D) immune globulin (RhoGAM) within 72 hours after birth.
A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the following assessments. The vaginal exam is deferred until the physician is in attendance. The client is placed on electronic fetal monitoring and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring. a. Placental previa b. Active labor has started c. placental abruption d. hidden placental abruption
d. hidden placental abruption rationale: the clients signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention and imminent birth
In which situation would a dilation and curettage (D&C) be indicated a. complete abortion at 8 weeks b. incomplete abortion at 16 weeks c. threatened abortion at 6 weeks d. incomplete abortion at 10 weeks.
d. incomplete abortion at 10 weeks rationale: D&C is carried out to remove the products of conception from the uterus and can be done safely until week 14 of gestation.
A placenta previa when the placental edge just reaches the internal os is called a. total b. partial c. low-lying d. marginal
d. marginal rationale: a placenta previa that does not cover any part of the cervix is termed marginal. partial previa - placenta within 3cm of cervix
A primigravida of 28 years old is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following. a. She should be isolated from her family b. this condition is caused by psychogenic factors c. the treatment is similar to that for morning sickness d. she should be assessed for signs of dehydration and starvation.
d. she should be assessed for signs of dehydration and starvation rationale: the cause of hyperemesis gravidarum is unknown, but dehydration and starvation are the major complications.
A client with no prenatal care delivers a health male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension do you think the client is exhibiting. a. pregnancy-induced hypertension (PIH) b. gestational hypertension c. pre-eclampsia superimposed on chronic hypertension d. undiagnosed chronic hypertension
d. undiagnosed chronic hypertension rationale: even though the client has no documented prenatal care or medical history, she does relate a family history that is positive for heart disease
Which assessment finding on the fetal monitor strip supports a diagnosis of abruptio placentae. a. FHR of 150 bpm b. Moderate variability of FHR c. contractions every 3 mins d. uterine resting tone of 30 mm Hg
d. uterine resting tone of 30 mm Hg rationale: Abruptio placentae results in uterine irritability and a high resting uterine tone.
which assessment finding indicates the development of pre-eclampsia in the antepartum client a. slight edema of feet and ankles b. increased urine output c. blood pressure of 128/80 mm Hg d. weight gain of 3 pounds in 1 week
d. weight gain of 3 pounds in 1 week rationale: generalized edema often occurs with pre-eclampsia. Edema may first manifest as a rapid weight gain
A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate a. gastrointestinal upset b. effects of magnesium sulfate c. anxiety caused by hospitalization d. worsening disease and impending convulsion
d. worsening disease and impending convulsion rationale: headache and visual disturbances are caused by increased cerebral edema.
