Prep
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?
"The injection is given in the space outside the spinal cord."
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? Provide a well-lit room. Keep head of bed slightly elevated. Place the client in a supine position. Keep the suction equipment readily available.
Keep the suction equipment readily available. Explain: 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.
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? Urine protein Ability to sleep Hemoglobin Respiratory rate
Respiratory rate The level of magnesium in therapeutic range is 4 to 8 mg/dL. If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest.
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: longer length of labor. increased number of overall pregnancies. increasing birth weight. poor quality of prenatal care.
increasing birth weight.
Which spotaneous abortion has a closed cervix? a. missed b. complete c. inevitable d. incomplete e. threatened f. habitual
missed complete threatened
A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose? blood pressure patellar reflex heart rate anxiety level
patellar reflex Explain: 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.
A client who is in labor presents with shoulder dystocia of the fetus. Which is an important nursing intervention? A. Assist with positioning the woman in squatting position. B. Assess for reports of intense back pain in first stage of labor. C. Anticipate possible use of forceps to rotate to anterior position at birth. D. Assess for prolonged second stage of labor with arrest of descent.
A. Assist with positioning the woman in squatting position.
A client at 32 weeks' gestation has been admitted to the labor and birth unit with preterm labor. Which medication would the nurse be likely to administer to reduce the risk of complications in the preterm newborn? corticosteroids magnesium sulfate nifedipine indomethacin
corticosteroids Explain: Corticosteroids are given to help reduce or prevent the frequency and severity of respiratory distress syndrome in preterm infants delivered between 24 and 34 weeks' gestation. Medications most commonly used for tocolysis include magnesium sulfate, indomethacin, and nifedipine. Reference:
A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client? a. administering oxytocin b. amniotomy c. Hands and knees position d. comfort measures
a. administering oxytocin Explain: Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position. pg 759
When assessing a pregnant woman with vaginal bleeding, which finding would lead the nurse to suspect an inevitable abortion? a) No passage of fetal tissue b) Slight vaginal bleeding c) Closed cervical os d) Strong abdominal cramping
d) Strong abdominal cramping
A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?' A. assess for cleft palate B. extensive lacerations C. monitor for a cardiac anomaly D. brachial plexus assessment
D. brachial plexus assessment
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? blood typing of mothers with type A or B blood Rho(D) immune globulin administration to Rh-negative women amniocentesis cerclage
Rho(D) immune globulin administration to Rh-negative women Explain: Rh incompatibility can be prevented with the use of Rho(D) immune globulin.
A woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor? variable deceleration pattern fetal heart rate (FHR) increase to 200 beats/min early deceleration with each contraction late deceleration with late recovery following contraction
variable deceleration pattern Explain: Umbilical cord prolapse can be seen after the membranes have ruptured, when the FHR is displaying a sudden variable deceleration FHR pattern on a fetal monitor. It is not uncommon for FHR to increase following a procedure. Early deceleration with each contraction is seen when the fetal head is being compressed through the pelvic opening. Late deceleration with late recovery following contraction is associated with uteroplacental insufficiency (UPI).
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: no more than three children is recommended. as long as she receives Rho(D) immune globulin, there is no limit. only her next child will be affected. she will have to ask her primary care provider.
as long as she receives Rho(D) immune globulin, there is no limit. Explain: Because Rho(D) immune globulin supplies passive antibodies, it prevents the woman from forming antibodies. Without antibodies that could affect the fetus, the woman could have as many children as she wants.
The nurse through assessment can best differentiate between placenta previa and abruptio placentae by which of the following signs and or symptoms. a) Bleeding amount and consistency. b) Low back pain. c) Shape of the abdomen. d) Uterine tone and contractions of the uterus.
d) Uterine tone and contractions of the uterus. explain: With placenta previa the bleeding is often bright red and painless, with abruptio placentae the bleeding is usually dark and painful. The uterus is firm and hard and painful with the abruption; the uterus is often soft and lacks tone with the previa. The contractions of the uterus, low back pain, or the shape of the abdomen do not help to distinguish between placenta previa and abruption placentae
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? promote maternal D antibody formation. prevent maternal D antibody formation. stimulate maternal D immune antigens. prevent fetal Rh blood formation.
prevent maternal D antibody formation. Explain: 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.
A client experiencing a threatened abortion is concerned about losing the pregnancy and asks what she can do to help save her baby. What is the most appropriate response from the nurse? "Carry on with the activity you engaged in before this happened." "Restrict your physical activity to moderate bed rest." "Strict bed rest is necessary so as not to jeopardize this pregnancy." "There is no research evidence that I can recommend to you."
"Restrict your physical activity to moderate bed rest." Explain: With a threatened abortion, moderate bedrest, light activities, and supportive care are recommended. Regular physical activity may increase the chances of miscarriage.
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? painless bright red vaginal bleeding increased fetal movement "knife-like" abdominal pain with vaginal bleeding generalized vasospasm
"knife-like" abdominal pain with vaginal bleeding Explain: The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.
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 systolic blood pressure increase of 10 mm Hg Weight gain of 1.2 lb (0.54 kg) during the past 1 week A dipstick value of 2+ for protein Pedal edema
A dipstick value of 2+ for protein Explain: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia
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? Assess fetal heart rate Administer oxygen by face mask Insert a Foley catheter Prepare the client for an epidural
Assess fetal heart rate Expain: 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.
Before calling the health care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the health care provider? Make sure the epidural medication is turned down. Check for a full bladder. Make sure the client is lying on her left side. Assess vital signs every 30 minutes.
Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.
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? Take a low-dose antihypertensive prophylactically. Have her blood pressure checked at every prenatal visit. Monitor the client for headaches or swelling on the body. Take one aspirin every day.
Have her blood pressure checked at every prenatal visit. Explain: Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits
A nursing instructor is conducting a session exploring the signs and symptoms of eclampsia to a group of student nurses. The instructor determines the session is successful after the students correctly choose which signs indicating eclampsia? Select all that apply. proteinuria hyperglycemia hyperreflexia blurring of vision auditory hallucinations
blurring of vision hyperreflexia proteinuria Explain: Eclampsia is usually preceded by an acute increase in blood pressure as well as worsening signs of multiorgan system failure seen as increasing liver enzymes, proteinuria, and symptoms such as blurred vision and hyperreflexia.
A woman who is 31 weeks pregnant presents at the emergency room with bright red vaginal bleeding. She says the onset of the bleeding was sudden and she has no pain. The nurse is most likely to assist the physician or technician with which exam? a) A blood transfusion b) An abdominal ultrasound c) A transvaginal ultrasound d) A digital cervical exam
c) A transvaginal ultrasound Explain: The use of a transvaginal ultrasound is the diagnostic test of choice; it is 100% accurate in prediction of placenta previa, while abdominal ultrasound is only 95% accurate.
woman is being admitted to your hospital unit for severe preeclampsia. When deciding on where to place her, which of the following areas would be most appropriate? a) Near the elevator so she can be transported quickly b) Near the nurse's station so she can be observed closely c) By the nursery so she can maintain hope she will have a child d) In the back hallway where there is a quiet, private room
d) In the back hallway where there is a quiet, private room Explain: A sudden noise can trigger a seizure in a severely preeclamptic woman. Room placement, therefore, should not be near noise, such as the nursery, the elevator, or nurse's station.
A woman who is 42 weeks' pregnant comes to the clinic. During the visit, which assessment should the nurse prioritize? determining an accurate gestational age asking her about the occurrence of contractions checking for spontaneous rupture of membranes measuring the height of the fundus
determining an accurate gestational age
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? magnesium sulfate nifedipine indomethacin betamethasone
magnesium sulfate Explain: Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent.
A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable abortion? strong abdominal cramping slight vaginal bleeding closed cervical os no passage of fetal tissue
strong abdominal cramping Explain: Strong abdominal cramping is associated with an inevitable spontaneous abortion. 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 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 1+ ankle edema mild hand edema proteinuria of 200 mg/24 hours
urine output of less than 15 ml/hr Explain: Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 500 mg in 24 hours, oliguria of less than 15 ml/hr, cerebral and visual symptoms, and rapid weight gain.
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? Exposure to chemicals or radiation Advanced maternal age Chromosomal defects in the fetus Faulty implantation
Chromosomal defects in the fetus Explain: Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason.
A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority? Confine the client to bed rest in a darkened room. Administer oxygen by face mask. Keep the client on her side so that secretions can drain from her mouth. Check for vaginal bleeding every 15 minutes.
Confine the client to bed rest in a darkened room. Explanation: With severe preeclampsia, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because a bright light can also trigger seizures.
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? Check deep tendon reflexes. Measure fundal height. Palpate the fundus and check fetal heart rate. Obtain a voided urine specimen and determine blood type.
Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
The nurse would prepare a client for amnioinfusion when which action occurs? Severe variable decelerations occur and are due to cord compression. Fetal presenting part fails to rotate fully and descend in the pelvis. The fetus shows abnormal fetal heart rate patterns. Maternal pushing is compromised due to anesthesia.
Severe variable decelerations occur and are due to cord compression. Explain: Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid.
The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority? monitoring uterine contractility assessing signs of shock determining the amount of funneling assessing the amount and color of the bleeding
assessing the amount and color of the bleeding Explain: 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.