Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply. - blood pressure higher than 160/110 mm Hg - epigastric pain - oliguria - upper right quadrant pain - hyperbilirubinemia

Answer: - epigastric pain - upper right quadrant pain - hyperbilirubinemia Rationale: The signs and symptoms of HELLP syndrome are nausea, malaise, epigastric pain, upper right quadrant pain, demonstrable edema, and hyperbilirubinemia. Blood pressure higher than 160/110 mm Hg and oliguria are the symptoms of severe preeclampsia rather than HELLP syndrome.

What would be the physiologic basis for a placenta previa? A.) a loose placental implantation B.) low placental implantation C.) a placenta with multiple lobes D.) a uterus with a midseptum

Answer: B.) low placental implantation

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? A.) Monitor the client's beta-hCG level. B.) Monitor the mass with transvaginal ultrasound. C.) Monitor the client's vital signs and bleeding. D.) Monitor the fetal heart rate (FHR).

Answer: C.) Monitor the client's vital signs and bleeding. Rationale: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending spontaneous abortion (miscarriage). Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.

A woman at 9 weeks' gestation was unable to control the nausea and vomiting of hyperemesis gravidarum through conservative measures at home. With nausea and vomiting becoming severe, the woman was omitted to the obstetrical unit. Which action should the nurse prioritize? A.) bed rest with bathroom privileges B.) instruct on NPO status C.) establish IV for rehydration D.) administration of antiemetics

Answer: C.) establish IV for rehydration

The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement? A.) "If I have changes in my vision, I will lie down and rest." B.) "I will weigh myself every morning after voiding before breakfast." C.) "I will count my baby's movements after each meal." D.) "If I have a severe headache, I'll call the clinic."

Answer: A.) "If I have changes in my vision, I will lie down and rest." Rationale: Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampsia and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. Gaining weight is not necessarily a sign of worsening preeclampsia. The other choices are instructions which the client may be given to follow.

A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best? A.) "Please come in now for an evaluation by your health care provider." B.) "Lie on your left side and drink lots of water and monitor the bleeding." C.) "If the bleeding lasts more than 24 hours, call us for an appointment." D.) "Bleeding during pregnancy happens for many reasons, some serious and some harmless."

Answer: A.) "Please come in now for an evaluation by your health care provider." Rationale: Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best? A.) "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." B.) "I know that it is sad but the pregnancy must be terminated to save your life." C.) "The choice is up to you but the health care provider is recommending an induced abortion (medical abortion). D.) "You have experienced an incomplete abortion (miscarriage) and must have the placenta and any other tissues cleaned out."

Answer: A.) "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." Rationale: The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.

At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdominal pain that started suddenly about 1 hour ago and has not subsided. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. What should the nurse do next? A.) Assess fetal heart rate B.) Administer oxygen by face mask C.) Insert a Foley catheter D.) Prepare the client for an epidural

Answer: A.) Assess fetal heart rate Rationale: The presence of intense, knife-like abdominal pain with a sudden onset, a rigid and board-like abdomen, and no vaginal bleeding is evidence of a placental abruption (abruptio placentae). The next action by the nurse is to assess the fetal heart rate to determine the fetus's status. The priority is saving the life of the fetus and the mother. Inserting a urinary catheter and administering oxygen can be done once the status of the fetus is known. This client is not an appropriate candidate for an epidural at this time.

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? A.) Assess the client's vital signs. B.) Administer oxygen to the client. C.) Obtain a surgical consent from the client. D.) Provide emotional support to the client and significant other.

Answer: A.) Assess the client's vital signs.

The nurse recognizes that documenting accurate blood pressures is vital in the diagnosing of preeclampsia, severe preeclampsia and eclampsia. The nurse suspects preeclampsia based on which finding? A.) BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation B.) BP of 130/90 mm Hg on three occasions 3 hours apart C.) BP of 160/110 mm Hg on two occasions after 28 weeks' gestation D.) BP of 120/90 mm Hg on three occasions after 20 weeks' gestation

Answer: A.) BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation Rationale; Gestational hypertension is diagnosed when systolic blood pressure is over 140 mm Hg and/or diastolic pressure is over 90 mm Hg on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation in women known to be normotensive prior to this time and prior to pregnancy. Severe preeclampsia (i.e., preeclampsia with severe features) may develop suddenly or within days and bring with it high blood pressure of more than 160/110 mm Hg, cerebral and visual symptoms, and pulmonary edema.

A pregnant woman has been admitted to the hospital due to preeclampsia with severe features. Which measure will be important for the nurse to include in the care plan? A.) Institute and maintain seizure precautions. B.) Institute NPO status. C.) Admit the client to the middle of ICU where she can be constantly monitored. D.) Plan for immediate induction of labor.

Answer: A.) Institute and maintain seizure precautions.

A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client? A.) Lab work will be drawn to rule out acid-base imbalances. B.) An ultrasound will be done to reassess the correctness of gestational dates. C.) Since morning sickness is a common problem for pregnant women, the nurse will suggest the woman drink more fluids and eat crackers. D.) The nurse will encourage the woman to lie down and rest whenever she feels ill.

Answer: A.) Lab work will be drawn to rule out acid-base imbalances. Morning sickness that lasts all day and is severe is called hyperemesis gravidarum. It is much more serious than "morning sickness" and can lead to significant weight loss and electrolyte imbalance. Lab work needs to be drawn to determine the extent of electrolyte loss and acid-base balance. An ultrasound is performed but it is done to determine if the mother is experiencing a molar pregnancy. Treatment for hyperemesis gravidarum requires much more care than just rest, drinking fluids and eating crackers.

A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next? A.) Notify the health care provider B.) Provide health education C.) Assess the client for ketonuria D.) Document the client's blood pressure

Answer: A.) Notify the health care provider Rationale: The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The health care provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia.

A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)? A.) Onset of vaginal bleeding was sudden and painful B.) Fetus is in a breech position C.) Sonogram shows the placenta covering the cervical os D.) Uterus is soft between contractions

Answer: A.) Onset of vaginal bleeding was sudden and painful Rationale: Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? A.) Premature separation of the placenta B.) Preterm labor that was undiagnosed C.) Placenta previa obstructing the cervix D.) Possible fetal death or injury

Answer: A.) Premature separation of the placenta Rationale: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin? A.) STIs B.) amniocentesis C.) molar pregnancy D.) maternal trauma

Answer: A.) STIs Rationale; Indications for Rho(D) immune globulin include isoimmunization, ectopic pregnancy, chorionic villus sampling, amniocentesis, prenatal hemorrhage, molar pregnancy, maternal trauma, percutaneous umbilical sampling, therapeutic or spontaneous abortion, fetal death, or fetal surgery.

A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for? A.) Twin-to-twin transfusion syndrome (TTTS) B.) HELLP syndrome C.) TORCH syndrome D.) ABO incompatibility

Answer: A.) Twin-to-twin transfusion syndrome (TTTS) Rationale: When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.

A nurse is caring for a client who just experienced a spontaneous abortion (miscarriage) in her first trimester. When asked by the client why this happened, which is the best response from the nurse? A.) abnormal fetal development B.) rejection of the embryo through an immune response C.) implantation abnormality D.) lack of sufficient progesterone produced by the corpus luteum

Answer: A.) abnormal fetal development Rational: The most frequent cause of spontaneous abortion (miscarriage) in the first trimester of pregnancy is abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration. In other miscarriages, immunologic factors may be present or rejection of the embryo through an immune response may occur. Another common cause of early miscarriage involves implantation abnormalities. Miscarriage may also occur if the corpus luteum on the ovary fails to produce enough progesterone to maintain the decidua basalis.

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client? A.) diminished reflexes B.) elevated liver enzymes C.) seizures D.) serum magnesium level of 6.5 mEq/L

Answer: A.) diminished reflexes Rationale: Diminished or absent reflexes occur when a client develops magnesium toxicity. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.

A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP? A.) elevated lipoproteins B.) hemolysis C.) liver enzyme elevation D.) low platelet count

Answer: A.) elevated lipoproteins Rationale: The acronym HELLP represents hemolysis, elevated liver enzymes, and low platelets. This syndrome is a variant of preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect? A.) firm, rigid uterus on palpation B.) gradual onset of symptoms C.) fetal heart rate within normal range D.) absence of pain

Answer: A.) firm, rigid uterus on palpation Rationale: The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? A.) grade 2 B.) grade 1 C.) grade 3 D.) grade 4

Answer: A.) grade 2 Rationale: The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.

A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: A.) hydatidiform mole. B.) ectopic pregnancy. C.) placenta accrete. D.) hydramnios.

Answer: A.) hydatidiform mole. Rationale: Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.

Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with preterm premature rupture of membranes (PPROM) has completed how many weeks of gestation? A.) less than 37 weeks B.) less than 38 weeks C.) less than 39 weeks D.) less than 40 weeks

Answer: A.) less than 37 weeks Rationale: Preterm premature rupture of membranes (PPROM) is defined as the rupture of the membranes prior to the onset of labor in a woman who is less than 37 weeks' gestation. PROM (premature rupture of membranes) refers to a woman who is beyond 37 weeks' gestation, has presented with spontaneous rupture of the membranes, and is not in labor.

A pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially? A.) normal saline B.) dextrose 5% and water C.) 0.45% sodium chloride D.) albumin

Answer: A.) normal saline Rationale: For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.

A nurse is teaching a group of pregnant woman about bleeding that can occur early in pregnancy. The nurse determines that additional teaching is needed when the group identifies which condition as a common cause? A.) placenta previa B.) spontaneous abortion (miscarriage) C.) ectopic pregnancy D.) GTD

Answer: A.) placenta previa Rationale: The three most common causes of hemorrhage during the first half of pregnancy are spontaneous abortion (miscarriage), ectopic pregnancy, and GTD. Placenta previa occurs in the later weeks of gestation.

During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition? A.) preeclampsia without severe features B.) gestational hypertension C.) preeclampsia with severe features D.) eclampsia

Answer: A.) preeclampsia without severe features Rationale: A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to have preeclampsia without severe features when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart and mild facial or extremity edema. A woman has progressed to preeclampsia with severe features when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a tonic-clonic seizure or coma has occurred.

A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client? A.) preterm rupture of membranes followed by preterm birth B.) development of eclampsia C.) hemorrhaging D.) development of gestational trophoblastic disease

Answer: A.) preterm rupture of membranes followed by preterm birth Rationale: Even with precautions, in most instances of polyhydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)? A.) strong abdominal cramping B.) slight vaginal bleeding C.) closed cervical os D.) no passage of fetal tissue

Answer: A.) strong abdominal cramping Rationale: Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.

A 35-year-old client is seen for her 2-week postoperative appointment after a suction curettage was performed to evacuate a hydatidiform mole. The nurse explains that the human chorionic gonadotropin (hCG) levels will be reviewed every 2 weeks and teaches about the need for reliable contraception for the next 6 months to a year. The client states, "I'm 35 already. Why do I have to wait that long to get pregnant again?" What is the nurse's best response? A.) "After a curettage procedure, it is recommended that you give your body some time to build up its stores." B.) "A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy." C.) "Since you are at the end of your reproductive years, it is suggested that you don't try to have any more pregnancies." D.) "You may need chemotherapy, so we don't want to risk pregnancy."

Answer: B.) "A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy." Rationale: Because of the risk of choriocarcinoma, the woman receives extensive treatment. Therapy includes baseline chest X-ray to detect lung metastasis, plus a physical exam (including a pelvic exam). Serum B-hCG levels weekly until negative results are obtained three consecutive times, then monthly for 6 to 12 months. The woman is cautioned to avoid pregnancy during this time because the increasing B-hCG levels associated with pregnancy would cause confusion as to whether cancer had developed. If after a year B-hCG serum titers are within normal levels, a normal pregnancy can be achieved.

A pregnant client is admitted to a health care unit with disseminated intravascular coagulation (DIC). Which prescription is the nurse most likely to receive regarding the therapy for such a client? A.) Administer a ratio of 1 unit of blood to 4 units of frozen plasma. B.) Administer cryoprecipitate and platelets. C.) Aim at keeping the client's hematocrit above 20%. D.) Give each unit of blood to raise the hematocrit by 3 g/dl (30 g/L).

Answer: B.) Administer cryoprecipitate and platelets. Rationale: In a pregnant client with DIC, the nurse may be told to administer cryoprecipitate and platelets. Whole blood does not contain clotting factors. Therefore, a ratio of 4 units of blood to 1 unit of fresh frozen plasma, and not 1 unit of blood to 4 units of frozen plasma, should be considered. The nurse should aim at maintaining the client's hematocrit above 30% and not just 20%. The nurse should expect one unit of blood to increase the hematocrit by 1.5 g/dl (15 g/L) not 3g/dl (30 g/L).

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? A.) Take a low-dose antihypertensive prophylactically. B.) Have her blood pressure checked at every prenatal visit. C.) Monitor the client for headaches or swelling on the body. D.) Take one aspirin every day.

Answer: B.) Have her blood pressure checked at every prenatal visit. Rationale: 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 client whose membranes have prematurely ruptured is admitted to the hospital. Which nursing intervention is a priority? A.) Strict intake and output B.) Routine monitoring of vital signs C.) Continuous fetal monitoring D.) Urine dipstick daily

Answer: B.) Routine monitoring of vital signs Rationale: Rupture of the membranes without the onset of labor places the woman at risk for infection. The priority is to monitor temperature routinely by the completion of vital signs. Antibiotic therapy is often initiated as well, depending upon closeness of labor initiation (naturally or induced). The fetus will be monitored on a regular basis and then continuously when the labor process occurs. Urine analysis and strict intake and output are not typically completed.

A pregnant woman at 12 weeks' gestation comes to the office reporting she has begun minimal fresh vaginal spotting. She is distressed because her primary care provider indicates after examining her that they will "wait and see." Which response would be most appropriate from the nurse in answering this client's concerns? A.) Advise her to ask for a second care provider opinion. B.) Tell her that medication to prolong a 12-week pregnancy usually is not advised. C.) Explain that "wait and see" means that her care provider wants her to maintain strict bed rest. D.) Suggest she take an over-the-counter tocolytic just to feel secure.

Answer: B.) Tell her that medication to prolong a 12-week pregnancy usually is not advised. Rationale: Because many early pregnancy losses occur as the result of chromosome abnormalities, an aggressive approach to prolong these is not usually recommended. It would not be appropriate for the nurse to suggest an over-the-counter tocolytic, nor to tell the client that the care provider meant something else such as maintaining strict bed rest. Advising the client to seek a second opinion would not change the end results.

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving oxytocin and magnesium sulfate. The nurse will continue to monitor this client for progression to which condition? A.) gestational hypertension B.) eclampsia C.) severe preeclampsia D.) mild preeclampsia

Answer: B.) eclampsia Rationale: This woman is in severe preeclampsia and must be monitored for progression to eclampsia. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of oxytocin is to stimulate uterine contractions to hasten birth. The client has already progressed from mild preeclampsia to severe preeclampsia, and the nurse need to follow measures to prevent advancement of the disease process. Although preeclampsia results in a high blood pressure, the scenario described does not indicate a client with hypertension.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? A.) cord compression B.) fetal distress related to hypoxia C.) infection D.) central nervous system (CNS) involvement

Answer: B.) fetal distress related to hypoxia Rationale: When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider? A.) initial BP 120/80mm Hg; current BP 130/88 mm Hg B.) initial BP 100/70 mm Hg; current BP 140/90 mm Hg C.) initial BP 140/85 mm Hg; current BP 130/80 mm Hg D.) initial BP 110/60 mm Hg; current BP 112/86 mm Hg

Answer: B.) initial BP 100/70 mm Hg; current BP 140/90 mm Hg Rationale: A proteinuria of trace to 1+ and a rise in blood pressure to above 140/90 mm Hg is a concern the client may be developing preeclampsia. The blood pressures noted in the other options are not indicative of developing preeclampsia. The edema would not necessarily be indicative of preeclampsia; however, edema of the face and hands would be a concerning sign for severe preeclampsia.

A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose? A.) blood pressure B.) patellar reflex C.) heart rate D.) anxiety level

Answer: B.) patellar reflex Rationale: A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration is assurance the drug administration will be safe. Assessing the blood pressure, heart rate, or anxiety level would not reveal a potential magnesium toxicity.

A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? A.) promote maternal D antibody formation. B.) prevent maternal D antibody formation. C.) stimulate maternal D immune antigens. D.) prevent fetal Rh blood formation.

Answer: B.) prevent maternal D antibody formation. Rationale: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.

The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every 2 hours to detect which condition? A.) pulmonary hypertension B.) pulmonary edema C.) pulmonary emboli D.) pulmonary atelectasis

Answer: B.) pulmonary edema Rationale: In the hospital, monitor blood pressure at least every 4 hours for mild preeclampsia and more frequently for severe disease. In addition, it is important to auscultate the lungs every 2 hours. Adventitious sounds may indicate developing pulmonary edema.

The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents? A.) "I need a cesarean section if I develop this problem." B.) "If I develop this complication, I will have bright red vaginal bleeding," C.) "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." D.) "Since I am over 30, I run a much higher risk of developing this problem."

Answer: C.) "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." Rationale: Placental abruption (abruptio placentae) occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the ob/gyn will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a cesarean birth will be performed. Women older than 35 are also at higher risk for developing placental abruption.

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? A.) "Staples are put in the cervix to prevent it from dilating." B.) "The cervix is glued shut so no amniotic fluid can escape." C.) "Purse-string sutures are placed in the cervix to prevent it from dilating." D.) "A cervical cap is placed so no amniotic fluid can escape."

Answer: C.) "Purse-string sutures are placed in the cervix to prevent it from dilating." Rationale: The cerclage, or purse string suture, is inserted into the cervix to prevent preterm cervical dilation (dilatation) and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.

A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize? A.) A systolic blood pressure increase of 10 mm Hg B.) Weight gain of 1.2 lb (0.54 kg) during the past 1 week C.) A dipstick value of 2+ for protein D.) Pedal edema

Answer: C.) A dipstick value of 2+ for protein Rationale: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.

The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause? A.) Maternal smoking B.) Lack of prenatal care C.) Chromosomal abnormality D.) The age of the mother

Answer: C.) Chromosomal abnormality Rationale: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done and the mother should feel no fault. The nurse needs to encourage the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother.

A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor? A.) Exposure to chemicals or radiation B.) Advanced maternal age C.) Chromosomal defects in the fetus D.) Faulty implantation

Answer: C.) Chromosomal defects in the fetus

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? A.) Check deep tendon reflexes. B.) Measure fundal height. C.) Palpate the fundus and check fetal heart rate. D.) Obtain a voided urine specimen and determine blood type.

Answer: C.) Palpate the fundus and check fetal heart rate. Rationale: The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.

A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal? A.) Decrease blood pressure B.) Decrease protein in urine C.) Prevent maternal seizures D.) Reverse edema

Answer: C.) Prevent maternal seizures

A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first? A.) Administer oxygen to the client. B.) Notify the health care provider. C.) Reposition the client to left side. D.) Increase the rate of IV fluids.

Answer: C.) Reposition the client to left side. Rationale: The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus. After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.

A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect? A.) placenta previa B.) hyperemesis gravidarum C.) gestational trophoblastic disease D.) pregnancy-induced depression

Answer: C.) gestational trophoblastic disease Rationale: This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high hCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage.

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?' A.) lung sounds B.) oxygen saturation C.) reflexes D.) magnesium sulfate level

Answer: C.) reflexes

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse recognizes the client is being treated for which condition? A.) gestational hypertension B.) gestational diabetes C.) severe preeclampsia D.) postterm pregnancy

Answer: C.) severe preeclampsia Rationale: This woman is in severe preeclampsia and must be monitored for progression to eclampsia. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of the betamethasone is to try and hasten the maturity of the fetus's lungs for birth for a preterm fetus. The scenario described does not indicate a client with hypertension, gestational diabetes, or post-term (>42 weeks) pregnancy.

A client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation of an ectopic pregnancy? A.) Quantitative human chorionic gonadotropin (hCG) test B.) Qualitative human chorionic gonadotropin (hCG) test C.) Pelvic examination D.) Abdominal ultrasound

Answer: D.) Abdominal ultrasound Rationale: An ectopic pregnancy refers to the implantation of the fertilized egg in a location other than the uterus. Potential sites include the cervix, uterus, abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be made by an ultrasound, which would confirm that there was no uterine pregnancy. A quantitative hCG level may be completed in the diagnostic plan. hCG levels in an ectopic pregnancy are traditionally reduced. While this would be an indication, it would not provide a positive confirmation. The qualitative hCG test would provide evidence of a pregnancy, but not the location of the pregnancy. A pelvic exam would be included in the diagnostic plan of care. It would likely show an enlarged uterus and cause potential discomfort to the client but would not be a definitive finding.

A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure? A.) Contraction test B.) Nonstress test C.) Biophysical profile D.) Amniocentesis

Answer: D.) Amniocentesis Rationale: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.

A nurse is assessing a pregnant client with preeclampsia for suspected dependent edema. Which description of dependent edema is most accurate? A.) Dependent edema leaves a small depression or pit after finger pressure is applied to a swollen area. B.) Dependent edema occurs only in clients on bed rest. C.) Dependent edema can be measured when pressure is applied. D.) Dependent edema may be seen in the sacral area if the client is on bed rest.

Answer: D.) Dependent edema may be seen in the sacral area if the client is on bed rest. Rationale: The nurse should know that dependent edema may be seen in the sacral area if the client is on bed rest. Pitting edema leaves a small depression or pit after finger pressure is applied to a swollen area and can be measured. Dependent edema may occur in clients who are both ambulatory and on bed rest.

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client? A.) Provide a well-lit room. B.) Keep head of bed slightly elevated. C.) Place the client in a supine position. D.) Keep the suction equipment readily available.

Answer: D.) Keep the suction equipment readily available. Rationale: The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

A woman is being admitted to the obstetric unit for severe preeclampsia. When assigning room placement, which area would be most appropriate? A.) beside the supply room B.) near the staff elevator C.) across from the nurse's station D.) at the end of the hallway

Answer: D.) at the end of the hallway Rationale: A sudden noise can trigger a seizure in a severely preeclamptic woman. Room placement, therefore, should not be near a high traffic area or noise, such as by a supply room, the staff elevator, or nurse's station.

A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical? A.) increased perspiration B.) weight loss C.) susceptibility to infection D.) blood pressure elevation

Answer: D.) blood pressure elevation

A woman at 10 weeks' gestation comes to the clinic for an evaluation. Which assessment finding should the nurse prioritize? A.) report of frequent mild nausea B.) blood pressure of 120/84 mm Hg C.) history of bright red spotting 6 weeks ago D.) fundal height measurement of 18 cm

Answer: D.) fundal height measurement of 18 cm Rationale; A fundal height of 18 cm is larger than expected and should be further investigated for gestational trophoblastic disease (hydatidiform mole). One of the presenting signs is the uterus being larger than expected for date. Mild nausea would be a normal finding at 10 weeks' gestation. Blood pressure of 120/84 mm Hg would not be associated with hydatidiform mole and depending on the woman's baseline blood pressure may be within acceptable parameters for her. Bright red spotting might suggest a spontaneous abortion (miscarriage).

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements? A.) preeclampsia B.) placental abruption (abruptio placentae) C.) placenta previa D.) gestational hypertension

Answer: D.) gestational hypertension Rationale: Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Placental abruption (abruptio placentae), a separation of the placenta from the uterine wall; placenta previa (placenta covering the cervical os); and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.

The nurse is assessing a client at 12 weeks' gestation at a routine prenatal visit who reports something doesn't feel right. Which assessment findings should the nurse prioritize? A.) elevated hCG levels, enlarged abdomen, quickening B.) vaginal bleeding, increased hPL levels C.) visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen D.) gestational hypertension, hyperemesis gravidarum, absence of FHR

Answer: D.) gestational hypertension, hyperemesis gravidarum, absence of FHR Rationale: The early development of gestational hypertension/preeclampsia, hyperemesis gravidarum, and the absence of FHR are suspicious for gestational trophoblastic disease. The elevated levels of hCG lead to the severe morning sickness. There is no fetus, so FHR, quickening, and evidence of a fetal skeleton would not be seen. The abdominal enlargement is greater than expected for pregnancy dates, but hCG, not hPL, levels are increased.

A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy? A.) high number of pregnancies B.) multiple gestation pregnancy C.) use of oral contraceptives D.) history of endometriosis

Answer: D.) history of endometriosis Rationale: The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple abortions (elective terminations of pregnancy). Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.

Which measure would the nurse include in the plan of care for a woman with prelabor rupture of membranes if her fetus's lungs are mature? A.) reduction in physical activity level B.) observation for signs of infection C.) administration of corticosteroids D.) labor induction

Answer: D.) labor induction Rationale: With prelabor rupture of membranes (PROM) in a woman whose fetus has mature lungs, induction of labor is initiated. Reducing physical activity, observing for signs of infection, and giving corticosteroids may be used for the woman with PROM when the fetal lungs are immature.

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? A.) oxytocin B.) promethazine C.) ondansetron D.) methotrexate

Answer: D.) methotrexate Rationale: 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.

A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV? A.) urine protein B.) ability to sleep C.) hemoglobin D.) respiratory rate

Answer: D.) respiratory rate Rationale: A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time? A.) premature birth B.) hypertension C.) spontaneous abortion (miscarriage) D.) preterm labor

Answer; C.) spontaneous abortion (miscarriage) Rationale: The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for spontaneous abortion (miscarriage). Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.