Pregnancy at risk- complications
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? Obtain a voided urine specimen and determine blood type. Palpate the fundus and check fetal heart rate. Check deep tendon reflexes. Measure fundal height.
C 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 nurse is caring for a client undergoing treatment for ectopic pregnancy. Which symptom is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated? phrenic nerve irritation painless bright red vaginal bleeding fetal distress tetanic contractions
A The symptoms if rupture or hemorrhaging occurs before successfully treating the pregnancy are lower abdomen pain, feelings of faintness, phrenic nerve irritation, hypotension, marked abdominal tenderness with distension, and hypovolemic shock. Painless bright red vaginal bleeding occurring during the second or third trimester is the clinical manifestation of placenta previa. Fetal distress and tetanic contractions are not the symptoms observed in a client if rupture or hemorrhaging occurs before successfully treating an ectopic pregnancy.
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? "Continue normal activity, but take the pulse every hour." "Come to the health facility with any vaginal material passed." "Come to the health care facility if uterine contractions begin." "Maintain bed rest, and count the number of perineal pads used."
B 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 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? Decrease blood pressure Decrease protein in urine Prevent maternal seizures Reverse edema
C 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 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? Contraction test Nonstress test Biophysical profile Amniocentesis
D 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 young client gives birth to twin boys who shared the same placenta. For what serious complication should the nuse prepare? toxoplasmosis. other, rubella, cytomegalovirus, and genital herpes (TORCH) infection twin-to-twin transfusion syndrome (TTTS) hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome ABO incompatibility
B When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur. HELLP syndrome (which stands for hemolysis, elevated liver enzymes, low platelets count) is a hypertensive disorder of pregnancy that occurs most often as a complication of preeclampsia. TORCH infection is a group of infections commonly implicated in congenital anomalies. It stands for toxoplasmosis, other, rubella, cytomegalovirus, and genital herpes. ABO incompatibility is a condition where the newborn's blood type is different from the gestational parent's blood type. If the two blood types mix, the newborn's body may attack the red blood cells and break them down.
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)? closed cervical os slight vaginal bleeding no passage of fetal tissue strong abdominal cramping
D 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 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? Notify the health care provider. Administer oxygen to the client. Increase the rate of IV fluids. Reposition the client to left side.
D 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.
x 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? high number of pregnancies multiple gestation pregnancy use of oral contraceptives history of endometriosis
D 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 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 Possible fetal death or injury Preterm labor that was undiagnosed Placenta previa obstructing the cervix
A 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 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? Give birth vaginally Bed rest to maintain pregnancy as long as possible Notification of social support for loss of pregnancy Education on causes of cervical insufficiency for the future
B At 22 weeks' gestation, the fetus is not viable. The woman would be placed on total bed rest with every attempt made to halt any further progression of dilation (dilatation) of the cervix. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.
A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect? halts the progression of the abortion alleviates strong uterine cramping ensures passage of all the products of conception suppresses the immune response to prevent isoimmunization
C Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an abortion to ensure passage of all the products of conception. Rho(D) immune globulin is used to suppress the immune response and prevent isoimmunization.
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? Molar pregnancy Ectopic pregnancy Healthy pregnancy Placenta previa
B 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.
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? Lack of prenatal care Chromosomal abnormality The age of the mother Maternal smoking
B 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 nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first? Obtain a surgical consent from the client. Administer oxygen to the client. Provide emotional support to the client and significant other. Assess the client's vital signs.
D 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 pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis? platelet count hematocrit white blood cells LDH
D HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a variant of the preeclampsia/eclampsia syndrome. The diagnosis is based on laboratory test results, including: low hematocrit, elevated LDH, elevated AST, elevated ALT, elevated BUN, elevated bilirubin level, elevated uric acid and creatinine levels, and low platelet count. White blood cell counts are not used to evaluate for HELLP.
