NSG 333 Ch 19- Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy?

methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

recurrent pelvic infections Rationale: In the general population, most cases of ectopic pregnancy are the result of tubal scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy, irregular menses are not considered risk factors for ectopic pregnancy

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?

Institute and maintain seizure precautions. Explanation: The woman with preeclampsia with severe features should be maintained on complete bed rest in a dark and quiet room to avoid stimulation. The client is at risk for seizures; therefore, institution and maintenance of seizure precautions should be in place.

A client at 33 weeks' gestation comes to the emergency department with vaginal bleeding. Assessment reveals the following: • Onset of slight vaginal bleeding at 29 weeks with spontaneous cessation • Recent onset of bright red vaginal bleeding, more than with previous episode • No uterine contractions at present • Fetal heart rate within normal range • Uterus soft and nontender Based on the assessment findings, which condition would the nurse likely suspect?

Placenta previa Rationale: The assessment findings suggest placenta previa, a bleeding condition that occurs during the last two trimesters of pregnancy. It is characterized by slight bright red vaginal bleeding initially that stops spontaneously and then recurs later in amounts greater than the initial episode; absence of pain/contractions; soft, relaxed uterine tone; and a fetal heart rate within normal parameters. Placental abruption is characterized by a sudden onset with concealed or visible dark vaginal bleeding, utuerie tenderness and pain, with a firm or rigid uterus and fetal distress. The hallmark of ectopic pregnancy is abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period. If ectopic rupture or hemorrhage occurs before treatment begins, symptoms may worsen and include severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity; feelings of faintness; referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation; hypotension; marked abdominal tenderness with distention; and hypovolemic shock. Polyhydramnios is initially suspected when uterine enlargement, maternal abdominal girth, and fundal height are larger than expected for the fetus's gestational age. With polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid growth of the uterus is noted. Shortness of breath and uterine contractions from overstretching may occur. Often the fetal parts and heart rate are difficult to obtain because of the excess fluid present.

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?

firm, rigid uterus on palpation Explanation: 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 in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.

hemolysis elevated liver enzymes low platelet count Explanation: The HELLP syndrome is a syndrome involving hemolysis (microangiopathic hemolytic anemia), elevated liver enzymes, and a low platelet count. Hyperthermia and leukocytosis are not features of HELLP syndrome.

A client is 11 weeks' pregnant after many years trying to conceive. After arriving home from a normal prenatal visit, she experiences mild cramping and has a gush of bright red vaginal bleeding. She calls the nurse and reports having soaked a pad with fresh blood in fewer than 30 minutes. The uterine cramping is worsening. What is the most appropriate response from the nurse?

"You need to seek immediate attention from the primary care provider." Explanation: Pregnancy loss during the early weeks of pregnancy may seem like a heavy menstrual period. A primary care provider should assess blood loss of this amount with or without uterine cramping as soon as possible.

A pregnant client with preeclampsia is being treated with intravenous magnesium sulfate. The nurse assesses the client's deep tendon reflexes and grades them as 4+. The nurse notifies the health care provider about this finding, describing them using which term to ensure accurate communication?

Clonus Rationale: The National Institute of Neurological Disorders and Stroke, a division of the National Institutes of Health, published a scale in the early 1990s that, though subjective, is used widely today. It grades reflexes from 0 to 4+. Grades 2+ and 3+ are considered normal, and grades 0 which indicates an absent reflex and 4 which indicates clonus may indicate pathology. Because these are subjective assessments, to improve communication of reflex results, condensed descriptor categories such as absent, average, brisk, or clonus should be used rather than numeric codes. A 4+ grade indicates clonus which is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms central nervous system involvement.

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?

Palpate the fundus and check fetal heart rate. Explanation: 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 woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?

"I have a toddler and preschooler at home who need my attention." Rationale: Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home. Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions.

A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best?

"Please come in now for an evaluation by your health care provider." Explanation: 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 nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

elevated liver enzymes Rationale: HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia is not a part of this syndrome. HELLP may increase the woman's risk for DIC but it is not an assessment finding.

While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Which information would the nurse use to support this suspicion? Select all that apply.

history of diabetes reports of shortness of breath difficulty obtaining fetal heart rate Rationale: Factors such as maternal diabetes or multiple gestations place the woman at risk for hydramnios. In addition, there is a discrepancy between fundal height and gestational age, such that a rapid growth of the uterus is noted. Shortness of breath may result from overstretching of the uterus due to the increased amount of amniotic fluid. Often, fetal parts are difficult to palpate and fetal heart rate is difficult to obtain because of the excess fluid present.

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?

respiratory rate Explanation: 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.

It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

at 28 weeks' gestation and again within 72 hours after birth Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.

A client in their third trimester is being seen in the clinic with new-onset fever, lethargy, and painful urination. Vital signs: temperature, 101.2°F (38.4°C); blood pressure, 110/70 mm Hg; heart rate, 98 beats/min. Drag words from the choices below to fill in each blank in the following sentence.

The nurse recognizes that the client is at risk for developing urinary tract infection (UTI) as evidenced by painful urination. Explanation: The client has some of the signs and symptoms of a urinary tract infection (UTI), such as fever and painful urination. One indicator of a UTI is painful urination, which the client is experiencing. There are no indications that the infection has progressed into pyelonephritis. There is no indication that the client is at risk for placenta previa. Based on the client's blood pressure, the client is not at risk for eclampsia. The client's report of lethargy is most likely due to the fever and being in the third trimester. The client's blood pressure of 110/70 mm Hg is within normal limits. The client's heart rate of 98 beats/min is within normal range.

A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority?

oxygenation Rationale: As with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable.

During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume?

40% Explanation: Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock.

A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply

abdominal tenderness elevated maternal pulse rate cloudy malodorous fluid Rationale: Possible signs of infection associated with premature rupture of membranes include elevation of maternal temperature and pulse rate, abdominal/uterine tenderness, fetal tachycardia over 160 bpm, elevated white blood cell count and C-reactive protein levels, and cloudy, foulsmelling amniotic fluid.

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

calcium gluconate Rationale: The woman is at risk for magnesium toxicity. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

dark red vaginal bleeding rigid uterus absent fetal heart tones Rationale: Assessment findings associated with a placental abruption include a sudden onset with concealed or visible dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones.

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

hemorrhage Rationale: With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage. Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy

A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia?

hyperreflexia Rationale: Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours, and hyperreflexia. Mild facial edema is associated with mild preeclampsia.

A woman pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem?

preeclampsia Rationale: Women with multiple gestations are at high risk for preeclampsia, preterm labor, polyhydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension Explanation: 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.

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 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." Explanation: 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 woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?

"Come to the health facility with any vaginal material passed." Explanation: This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so the material can be assessed for this.

A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor at home. The nurse determines that the teaching was successful based on which statements by the woman? Select all that apply.

"I should check my blood pressure twice a day." "I should complete a fetal kick count each day." "I'll call my health care provider if I have burning when I urinate." Rationale: The client should take her blood pressure twice daily, check and record weight daily, perform urine dipstick checks for protein twice daily, record the number of fetal kicks daily, and notify her health care provider if she experiences burning on urination.

A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching?

"It's okay for my husband and me to have sexual intercourse." Rationale: The woman with preterm prelabor rupture of membranes should monitor her baby's activity by performing fetal kick counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and avoid sitting in a tub bath.

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?

"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." Explanation: 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.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?

6.1 mEq/L Rationale: Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.

A nurse is reviewing an article about preterm prelabor rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply.

urinary tract infection low socioeconomic status smoking Rationale: High-risk factors associated with prelabor rupture of membranes (PROM) include low socioeconomic status, multiple gestation, low body mass index, tobacco use, preterm labor history, placenta previa, abruptio placenta, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.

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?

Amniocentesis Explanation: 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 in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?

Assess the client's vital signs. Explanation: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.

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?

Chromosomal defects in the fetus Explanation: Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.

An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate?

Contact the health care provider to report the client's feelings. Explanation: The client may be experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the only action needed at this time and there is a better action. Encouraging the client to be positive about her situation may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate, because the scenario described does not indicate that the nurse has the client's permission to share this information with the family.

A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?

Ectopic pregnancy Explanation: The most commonly reported symptoms of ectopic pregnancy are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered. A healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.

A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia?

Her mother had preeclampsia during pregnancy. Rationale: A family history of preeclampsia, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy.

A client comes to the emergency department with moderate vaginal bleeding. She says, "I have had to change my pad about every 2 hours and it looks like I may have passed some tissue and clots." The woman reports that she is 9 weeks' pregnant. Further assessment reveals the following: • Cervical dilation • Strong abdominal cramping • Low human chorionic gonadotropin (hCG) levels • Ultrasound positive for products of conception The nurse suspects that the woman is experiencing which type of spontaneous abortion?

Inevitable Rationale: Based on the assessment findings, the woman is likely experiencing an inevitable abortion characterized by vaginal bleeding, rupture of membranes, cervical dilation, strong abdominal cramping, possible passage of products of conception, and ultrasound and hCG levels indicating pregnancy loss. A threatened abortion is characterized by slight vaginal bleeding, no cervical dilation or cange in cervical consistency, mild abdominal cramping, close cervical os, and no passage of fetal tissue. An incomplete abortion is characterized by intense abdominal cramping, heavy vaginal bleeding and cervical dilation with passage of some products of conception. A complete abortion is characterized by a history of vaginal bleeding and abdominal pain along with passage of tissue and subsequent decrease in pain and decrease in bleeding.

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?

Keep the suction equipment readily available. Explanation: 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.

The health care provider prescribes PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which action would be most important for the nurse to do?

Maintain the client supine for 30 minutes after administration. Rationale: When PGE2 is prescribed, the gel should come to room temperature before administering it. Sterile technique should be used, and the client should remain supine for 30 minutes after administration. Rho(D) immune globulin is administered intramuscularly into the deltoid area.

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?

Monitor the client's vital signs and bleeding. Explanation: 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.

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching?

Placenta previa is an abnormally implanted placenta that is too close to the cervix. Explanation: Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless, bright red bleeding in the third trimester. Placental abruption is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor. Placental abruption can result in concealed or apparent dark red bleeding and is painful. Immediate intervention is required for placental abruption.

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?

Premature separation of the placenta Explanation: 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 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?

Prevent maternal seizures Explanation: The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.

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?

Reposition the client to left side. Explanation: 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.

The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?

Vaginal bleeding and no pain Explanation: Placenta previa includes bright red and painless vaginal bleeding, which is different from the dark red bleeding of placental abruption (abruptio placenta) accompanied by severe pain. This differentiates the two conditions. Uterine contractions with vaginal mucus may be indications of the start of labor with the mucus plug being discharged. The fetal heart rate, fundal height, and contour of the abdomen are normal components that are assessed during the labor process.

The nurse is transcribing messages from the answering service. Which phone message should the nurse return first?

a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria Explanation: The nurse should call the at-risk 35-year-old client first. She is 21 weeks and has symptoms (blurred vision) of preeclampsia. She also had an increase of protein in her urine (2+) and a 15% increase in her BP. The nurse will need more information to determine if the 38-week client may be in the early stages of labor, and if the 31-week client with flank pain has a kidney infection. The client with malaise and rhinitis will need to talk to the nurse last to find out what over-the-counter medication she is able to take.

A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?

assessing fetal heart tones by use of an external monitor Explanation: Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?

assessing the amount and color of the bleeding Explanation: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

A high-risk pregnant client is determined to have gestational hypertension. The nurse suspects that the client has developed preeclampsia with severe features based on which finding?

blurred vision Explanation: Visual symptoms such as blurred vision and blind spots suggest severe preeclampsia. Severe preeclampsia is characterized by a blood pressure of 160/110 mm Hg. Mild facial edema or hand edema occurs with mild preeclampsia. Proteinuria in severe preeclampsia is greater than 500 mg per 24 hours.

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?

diminished reflexes Explanation: 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?

elevated lipoproteins Explanation: 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.

The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome?

elevated liver enzymes Rationale: HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome.

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?

fetal distress related to hypoxia Explanation: 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 nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions?

fetal genetic abnormalities Rationale: The causes of spontaneous abortion are varied and often unknown. The most common cause for first-trimester abortions is fetal genetic abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely causes in first trimester, and maternal disease is more likely in the second trimester. Those occurring during the second trimester are more likely related to maternal conditions, such as cervical insufficiency, congenital, or acquired anomaly of the uterine cavity (uterine septum or fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, use of crack cocaine, inherited and acquired thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis.

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

foul odor Rationale: A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would suggest meconium. A blue color on Nitrazine testing and ferning indicate the presence of amniotic fluid.

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?

grade 2 Explanation: 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 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?

history of endometriosis Explanation: 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.

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:

hydatidiform mole. Explanation: 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.

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?

labor induction Explanation: 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.

What would be the physiologic basis for a placenta previa?

low placental implantation Explanation: The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

A nurse is reviewing the medical record of a pregnant client. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which condition?

low-lying placenta Explanation: Placenta previa is currently classified with two terms: "placenta previa" and "low-lying placenta." If the placental edge is less than 2 cm from the internal os but does not cover it, the placenta is reported as low-lying. If the placental edge covers the internal os, it is labeled as a placenta previa. Placenta accreta spectrum includes three conditions. Accreta is the most common and is a condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle. Placenta increta occurs when the placenta invades the myometrium, and placenta percreta occurs when it has extended through the myometrium and uterine serosa and adjacent tissue.

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

nothing by mouth (NPO) Rationale: Typically, on admission, the woman with hyperemesis has oral food and fluids withheld to rest the gut and receives parenteral fluids to rehydrate and reduce the symptoms. Once the condition stabilizes, oral intake is gradually increased. Total parenteral nutrition may be used if the client's condition does not improve with several days of bed rest, gut rest, IV fluids, and antiemetics. Labetalol is an antihypertensive agent that may be used to treat gestational hypertension, not hyperemesis.

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?

preterm rupture of membranes followed by preterm birth Explanation: 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 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?

prevent maternal D antibody formation. Explanation: 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 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?

reflexes Explanation: Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.

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?

spontaneous abortion (miscarriage) Explanation: 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.

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)?

strong abdominal cramping Explanation: 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 woman in week 16 of her pregnancy calls her primary care provider's office to report that she has experienced abdominal cramping, vaginal spotting, and the passing of tissue. The nurse instructs the client to bring the passed tissue to the hospital with her. What is the correct rationale for this instruction?

to determine whether gestational trophoblastic disease is present Explanation: Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. This is why it is important for any woman who begins to miscarry at home to bring any clots or tissue passed to the hospital with her. The presence of clear fluid-filled cysts changes the diagnosis from a simple miscarriage to gestational trophoblastic disease. The client is not instructed to bring in passed tissue to determine whether infection is present or the fetus is viable or to determine the stage of development of the fetus.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

deep tendons reflexes 2+ Rationale: With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.

A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make?

"Drink fluids in between meals rather than with meals." Rationale: Suggestions to minimize nausea and vomiting include avoiding tight waistbands to minimize pressure on the abdomen, eating small frequent meals throughout the day, separating fluids from solids by consuming fluids in between meals; and avoiding lying down or reclining for at least 2 hours after eating.

A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse?

"I can understand your need to find an answer to what caused this. Let's talk about this further." Explanation: Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful?

"I will be sure to avoid getting pregnant for at least 1 year." Rationale: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?

"I'm sorry you lost your baby." Rationale: Telling the client that the nurse is sorry for the loss acknowledges the loss to the woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client that the baby was not formed is inappropriate and discounts any feelings or beliefs that the client has.

A client who has experienced an incomplete abortion is prescribed mifepristone to assist in removing the retained products of conception. Which medication would the nurse expect to adminster if prescribed before administering mifepristone?

Antiemetic to minimize nausea Rationale: For the client receiving mifepristone, the nurse would anticipate administering an antiemetic beforehand to reduce nausea and vomiting. Acetaminophen would be useful for pain relief, not an opioid. VItamin K or a diuretic would not be appropriate when administering mifepristone. Vitamin K would be used to counteract bleeding such as that associated with heparin administration. A diuretic would be appropriate to promote fluid excretion with fluid overload.