NUR 2420 Maternal Nursing Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

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."

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."

A nurse is providing discharge teaching for a pregnant client with preeclampsia who will be managed at home on bedrest. The nurse determines that the teaching was successful based on which client statement?

"I need to drink about 8 glasses of water a day."

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?

"If I have changes in my vision, I will lie down and rest."

A pregnant client with preterm premature rupture of the membranes is being discharged home. A nurse is preparing the client's discharge teaching plan. Which instructions would the nurse include? Select all that apply.

"If you notice your belly starting to tighten, call your health care provider." "Check your temperature each day, reporting any increase immediately."

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?

"Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain."

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."

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."

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?

"knife-like" abdominal pain with vaginal bleeding

A student nurse asks the instructor what percentage of clinically recognized pregnancies end in miscarriages during the first trimester. Which response from the nurse is the most accurate?

15% to 20%

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%

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 dipstick value of 2+ for protein

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?

Abdominal ultrasound

A nurse is caring for a client with hyperemesis gravidarum. Which nursing action is the priority for this client?

Administer IV normal saline with vitamins and electrolytes.

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

The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?

Assess the Rh of the baby.

When caring for a client with premature rupture of membranes (PROM), the nurse observes an increase in the client's pulse. What should the nurse do next?

Assess the client's temperature.

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.

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?

BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?

Dark red, "clumpy" vaginal discharge

A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (dilatation) to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?

Bed rest to maintain pregnancy as long as possible

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?

Chromosomal abnormality

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

A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia?

Coma occurs after seizure.

A client has been admitted to the hospital with a diagnosis of preeclampsia with severe features. Which nursing intervention is the priority?

Confine the client to bed rest in a darkened room.

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.

What special interventions would the nurse implement in a client who is carrying twin fetuses?

Demonstrate to the client how to perform fetal movement (kick) counts after 32 weeks.

A pregnant client with hyperemesis gravidarum needs advice on how to minimize nausea and vomiting. Which instruction should the nurse give this client?

Eat small, frequent meals throughout the day.

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

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?

Have her blood pressure checked at every prenatal visit.

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?

Immediate surgery

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.

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.

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?

Lab work will be drawn to rule out acid-base imbalances.

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.

A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. Which assessment findings should the nurse prioritize for this client? Select all that apply.

Nausea and vomiting Generalized edema Epigastric pain and tenderness

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?

Notify the health care provider

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)?

Onset of vaginal bleeding was sudden and painful

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.

The nurse understands the need to be aware of the potential of bleeding disorders in pregnant clients. Which disorder should she be aware of that occurs in the second trimester?

Placenta previa

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.

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

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

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.

A nurse is conducting a presentation for a group of pregnant women about conditions that can occur during pregnancy and that place the woman at high-risk. When discussing blood incompatibilities, which measure would the nurse explain as most effective in preventing isoimmunization during pregnancy?

Rho(D) immune globulin administration to Rh-negative women

The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for placental abruption (abruptio placentae). Which assessment finding should the nurse prioritize?

Sharp fundal pain and discomfort between contractions

The nurse is caring for a woman at 32 weeks' gestation with severe preeclampsia. Which assessment finding should the nurse prioritize after the administration of hydralazine to this client?

Tachycardia

A client is 20' weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client?

The client has pink vaginal discharge and pelvic pressure.

A young client gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?

Twin-to-twin transfusion syndrome (TTTS)

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

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition?

a client who had a myomectomy to remove fibroids

A nurse is caring for a client who just experienced a spontaneous abortion (miscarriage) in the first trimester. When asked by the client why this happened, which is the best response from the nurse?

abnormal fetal development

A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that:

as long as she receives Rho(D) immune globulin, there is no limit.

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

A woman is being admitted to the obstetric unit for severe preeclampsia. When assigning room placement, which area would be most appropriate?

at the end of the hallway

Which assessment findings, experienced by the client at 36 weeks' gestation, would the nurse document as diagnostic signs of severe preeclampsia? Select all that apply.

blood pressure of 164/110 mm Hg elevated liver enzymes +1 proteinuria Elevated serum creatinine

A pregnant client is hospitalized because of preeclampsia. Magnesium sulfate is ordered to prevent eclampsia. When preparing to administer the magnesium sulfate, the nurse would ensure that which medication would be readily available?

calcium gluconate

A pregnant client with multiple gestation arrives at the maternity clinic for a regular antenatal check up. The nurse would be aware that client is at risk for which perinatal complication?

congenital anomalies

A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition?

diabetes

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

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

A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying which situation(s) as needing to be reported? Select all that apply.

dizziness blurred vision excessive heartburn

A client visits a health care facility reporting amenorrhea for 10 weeks, fatigue, and breast tenderness. Which assessment finding(s) will the nurse prioritize for immediate intervention? Select all that apply.

elevated human chorionic gonadotropin (hCG) levels absence of fetal heart sounds hyperemesis gravidarum

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?

establish IV for rehydration

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

A nurse is providing care to a pregnant woman with preterm prelabor rupture of membranes (PPROM). On admission, the client's baseline information was as follows: temperature, 97.6°F (36.5°C); pulse, 76 beats/minute; fetal heart rate, 136 beats/minute; white blood cell count, 7 x 103cells/mm3 (7.0 x 109/L). Now, 8 hours later, assessment reveals the following: temperature, 99.6°F (37.7°C); pulse, 82 beats/minute; fetal heart rate, 180 beats/minute; white blood cell count, 8.5 x 103 cells/mm3 (8.5 X 109/L). The nurse suspects a possible infection based on the change in which parameter?

fetal heart rate

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

A woman at 10 weeks' gestation comes to the clinic for an evaluation. Which assessment finding should the nurse prioritize?

fundal height measurement of 18 cm

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

gestational hypertension

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?

gestational hypertension, hyperemesis gravidarum, absence of FHR

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

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

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.

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?

initial BP 100/70 mm Hg; current BP 140/90 mm Hg

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

Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a client who presents with preterm premature rupture of membranes (PPROM) has completed how many weeks of gestation?

less than 37 weeks

What would be the physiologic basis for a placenta previa?

low placental implantation

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

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

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?

normal saline

A pregnant client with preeclampsia with severe features has developed HELLP syndrome. In addition to the observations necessary for preeclampsia, what other nursing intervention is critical for this client?

observation for bleeding

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?

preeclampsia without severe features

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.

The nurse is admitting a G3 P2 client at 38 weeks' gestation who arrived reporting painless bleeding from the vagina leading to the diagnosis of placenta previa. When questioned by the client as to what caused this, which most likely factor should the nurse point out in her answer?

previous cesarean birth

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?

pulmonary edema

A woman has presented to the emergency department with symptoms that suggest an ectopic pregnancy. Which finding would lead the nurse to suspect that the fallopian tube has ruptured?

referred shoulder pain

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

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

A nurse is providing care to a pregnant client hospitalized with preeclampsia. The nurse immediately notifies the health care provider that the client has developed eclampsia based on which finding?

seizure activity

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)

A nurse is caring for a pregnant client admitted with mild preeclampsia. Which assessment finding should the nurse prioritize?

urine output of less than 15 ml/hr

A pregnant client at 24 weeks' gestation arrives in the office and reports that her feet and legs are swelling. During a client evaluation, the nurse notes that she can elicit a 4-mm skin depression that disappears in 10 to 15 seconds. The client is considered at risk for preeclampsia. What additional assessment would be beneficial for the nurse to complete?

weight gain

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."

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

methotrexate

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

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

The nurse is caring for an Rh-negative nonimmunized client at 14 weeks' gestation. What information would the nurse provide to the client?

Obtain Rho(D) immune globulin at 28 weeks' gestation.

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?

gestational trophoblastic disease

A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination, there is an elevated human chorionic gonadotropin (hCG) level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition?

gestational trophoblastic disease

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