Unit 3

Match the following s/sx for each abruption 1. Marginal 2. Partial/central 3. Complete A. Lack of fetal heart tones B. Blood noticed of vaginal exam C. Pain is the primary symptom

1. B 2. C 3. A

Diagnosis of severe preeclampsia...what will the protein levels be?

5 grams protein in a 24 hr urine collection or a dipstick of 3+

Most often definite treatment for HELLP?

Delivery of baby

When responding to the patient in question 7, the intervention that takes priority is to: a. Reduce anxiety. b. Arrange shelter. c. Contact out-of-area family. d. Hospitalize and place the patient on suicide precautions.

a. Reduce anxiety.

What is the priority nursing action when caring for a client with disseminated intravascular coagulation? A. Monitor for Homans sign. B. Avoid giving intramuscular injections. C. Take temperatures via the rectal route. D. Apply sequential compression stockings.

B. Avoid giving intramuscular injections. Massive amounts of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homans sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Sequential compression stockings are used to prevent thrombophlebitis

A pregnant woman is in a relationship with a male who routinely abuses her. Her unborn child may engage in high-risk behavior as a teen as a result of: a. Maternal stress b. Parental nurturing c. Appropriate stress responses in the brain d. Memories of the abuse

a. Maternal stress

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced

Which situation demonstrates use of primary care related to crisis intervention? a. Implementation of suicide precautions for a depressed patient b. Teaching stress reduction techniques to a first-year college student c. Assessing coping strategies used by a patient who attempted suicide d. Referring a patient with schizophrenia to a partial hospitalization program

b. Teaching stress reduction techniques to a first-year college student

A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the last 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus

2. Papilledema. The nurse would expect to see papilledema.TEST-TAKING TIP: Intracranial pressure (ICP) is present in a client with severe preeclampsia because she is third spacing large quantities of fluid. As a result of the ICP, the optic disk swells and papilledema is seen when the disk is viewed through an ophthalmoscope.

Which signs or symptoms would the client display if she were developing hemolysis A. Headache B. Constipation C. Abdominal pain D. Vaginal bleeding E. Flulike symptoms

A. Headache C. Abdominal pain E. Flulike symptoms Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes.

5. You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

A. Document your findings as normal.

Leading cause of early PPH A. Uterine atony B. Subinvolution of the Uterus C. Pelvic infection D. Retained placental fragments

A. Uterine atony

Why are children at a higher risk for trauma related problems

High respiratory rate→ makes them more vulnerable to noxious agents They don't have as much fluid reserve as an adult ( thus, more susceptible to dehydration) Have less circulating volume→ which means it only takes smaller amounts of blood loss to cause hypovolemic shock as compared to cause adults) Smaller airways Infants under 3 are obligate nose breather

(nurse sarah) Select all the patients below who are at risk for developing placenta previa: A. A 37 year old woman who is pregnant with her 7th child. B. A 28 year old pregnant female with chronic hypertension. C. A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen. D. A 20 year old pregnant female who is a cocaine user.

The answer is A and D. Risk factors for developing placenta previa include: Maternal age >35 years old, multiples (twins etc.), already had a baby, drug use: cocaine or smoking, surgery to the uterus that will leave scarring: fibroid removal, c-section etc.

Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events? a. "I attend my therapy sessions regularly." b. "Those intrusive memories are hidden for a reason and should stay hidden." c. "Keeping busy is the key to getting mentally healthy." d. "I've agreed to move in with my parents so I'll get the support I need."

a. "I attend my therapy sessions regularly."

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care? a. administer heparin. b. administer whole blood. c. treat the causative problem. d. administer fresh frozen plasma.

c. treat the causative problem Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

An incest survivor undergoing treatment at the mental health clinic is relieved when she learns that her anxiety and depression are: a. Going to be eradicated with treatment b. Normal and will soon pass c. Abnormal but will pass d. A normal reaction to posttraumatic events

d. A normal reaction to posttraumatic events

A client who is at risk for seizures as a result of severe preeclampsia is receiving an intravenous infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. A. Proteinuria B. Epigastric pain C. Respirations of 10 breaths/min D. Loss of patellar reflexes E. Urine output of 40 mL/hr

C. Respirations of 10 breaths/min D. Loss of patellar reflexes A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia. Magnesium sulfate toxicity is not accompanied by proteinuria; proteinuria is a sign of preeclampsia. Epigastric pain is associated with severe eclampsia, not magnesium sulfate toxicity. Urine output of 40 mL/hr is an acceptable output; an output of less than 30 mL/hr may contribute to the development of a toxic level of magnesium.

Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events? a. "I attend my therapy sessions regularly." b. "Those intrusive memories are hidden for a reason and should stay hidden." c. "Keeping busy is the key to getting mentally healthy." d. "I've agreed to move in with my parents so I'll get the support I need."

a. "I attend my therapy sessions regularly."

Assessment findings suggestive of peritonitis include (select all that apply) a. rebound tenderness. b. a soft, distended abdomen. c. dull, intermittent abdominal pain. d. shallow respirations with bradypnea. e. observing that the patient is lying still.

a. rebound tenderness. e. observing that the patient is lying still.

(nurse sarah) A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What risk factor below found in the patient's health history places her at risk for abruptio placentae? A. childhood polio B. preeclampisa C. c-section D. her age

The answer is B. Preeclampisa is a risk factor for experiencing abruptio placentae. The patient is at risk for developing this condition again since she is currently experiencing uncontrolled hypertension with this pregnancy.

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. A. Headache B.Constipation C. Abdominal pain D. Vaginal bleeding E. Flulike symptoms

A. Headache C. Abdominal pain E. Flulike symptoms Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding?* A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak

D. Check the drainage system for an air leak

(nurse sarah) Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A positive. What nursing interventions below will you include in the patient's care? Select all that apply: A. Routine vaginal examinations B. Monitoring vital signs C. Administer RhoGAM per MD order D. Assess internal fetal monitoring E. Placing patient on side-lying position F. Monitoring pad count G. Monitoring CBC and clotting levels

The answers are: B, E, F, and G. Option A is WRONG because vaginal exams are avoided to prevent causing damage to the placenta presenting at the cervical opening. Option C is WRONG because the patient is A positive and does NOT need RhoGAM, which is for patients who are RH negative. Option D is WRONG because external monitoring should be used NOT internal, which can damage the placenta at the cervical opening.

Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states: a. "I understand that imaginary friends are abnormal." b. "I understand that imaginary friends are a maladaptive behavior." c. "I understand that imaginary friends are a coping mechanism." d. "I understand that we should tell the child that imaginary friends are unacceptable."

c. "I understand that imaginary friends are a coping mechanism."

DIC is a disorder in which a. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels. b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts. c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage. d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature.

c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage. In disseminated intravascular coagulation (DIC), the coagulation process is stimulated, with resultant thrombosis and depletion of clotting factors, which leads to diffuse clotting and hemorrhage. The paradox of this condition is characterized by the profuse bleeding that results from the depletion of platelets and clotting factors

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a.Avoid other venipunctures. b.Apply dressings to the sites. c.Notify the health care provider. d.Give prescribed proton-pump inhibitors.

c.Notify the health care provider. The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly

Match symptoms to probable treatment 1. Paradoxical breathing 2. Tachycardia, absent breath sounds over left lung 3. Muffled heart sounds, HTN, neck vein distention A. stabilize chest wall B. chest tube insertion C. pericardiocentesis

1a, 2b, 3c Flail chest --> you want to stabilize chest wall Cardiac tamponade--> pericardiocentesis Pneumothorax --> chest tube insertion

The highest-priority goal of crisis intervention is: a. Anxiety reduction. b. Identification of situational supports. c. Teaching specific coping skills that are lacking. d. Patient safety

d. Patient safety

When counseling a preeclamptic client about her diet, what should the nurse encouragethe woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars.

3. It is important for the client to eat a well-balanced diet. - Sodium restriction is not recommended. - There is no need to increase fluid intake. - Although not the most nutritious of foods, there is no need to restrict the intake of simple sugars.

A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? 1. Altered glomerular filtration. 2. Cardiac failure. 3. Hepatic insufficiency. 4. Altered splenic circulation.

1. Altered glomerular filtration. Altered glomerular filtration leads to protein loss and, subsequently, to fluid retention, which can lead to swelling in the face and hands.The hypertension associated with preeclampsia results in poor perfusion of the kidneys. When the kidneys are poorly perfused, the glomerlular filtration is altered, allowing large molecules, most notably the protein albumin, to be lost through the urine. With the loss of protein, the colloidal pressure drops in the vascular tree, allowing fluid to third space. The body gets the message to retain fluids, exacerbating the problem. One of the early signs of the third spacing is the swelling of a client's hands and face.

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week gravid client to call the office if she experiences which of the following? 1. Headache and decreased output. 2. Puffy feet. 3. Hemorrhoids and vaginal discharge. 4. Backache

1. Headache and decreased output are signs of preeclampsia.TEST-TAKING TIP: It is important for the test taker to realize that, although some symptoms like puffy feet may seem significant, they are normal in pregnancy, while other symptoms like headache, which in a nonpregnant woman would be considered benign, may be potentially very important in a pregnant woman.

A client with mild preeclampsia, who has been advised to be on bed rest at home, asks why it is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bed rest will help you to conserve energy for your labor." 2. "Bed rest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."

3. "Reclining will increase the amount of oxygen that your baby gets." Bed rest, especially side-lying, helps to improve perfusion to the placenta.TEST-TAKING TIP: This question requires the nurse to have a clear understanding of the pathology of preeclampsia. Only with an understanding of the underlying disease, can the test taker be able to remember the rationale for many aspects of client care. The vital organs of preeclamptic clients are being poorly perfused as a result of the abnormally high blood pressure. When a woman lies on her side, blood return to the heart is improved and the cardiac output is also improved. With improved cardiac output, perfusion to the placenta and other organs is improved.

The nurse has assessed four primigravid clients in the prenatal clinic. Which of the women would the nurse refer to the nurse midwife for further assessment? 1. 10 weeks' gestation, complains of fatigue with nausea and vomiting. 2. 26 weeks' gestation, complains of ankle edema and chloasma. 3. 32 weeks' gestation, complains of epigastric pain and facial edema. 4. 37 weeks' gestation, complains of bleeding gums and urinary frequency.

3. Epigastric pain and facial edema are not normal. This client should be referred to the nurse midwife.The nurse must be prepared to identify clients with symptoms that are unexpected. This question requires the test taker to differentiate between normal signs and symptoms of pregnancy at a variety of gestational ages and those that could indicate a serious complication of pregnancy.

A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What adverse effects indicate that the serum magnesium level may be excessive? Select all that apply. A. Absence of the knee-jerk reflex B. Urine output of 100 mL/hr C. Blood pressure of 140/90 mm Hg D. Apical pulse of 80 beats/min E. Respiratory rate of 11 breaths/min

A. Absence of the knee-jerk reflex E. Respiratory rate of 11 breaths/min An absence of the knee-jerk reflex is a manifestation of hyporeflexia; it is a possible indication of magnesium sulfate toxicity. A respiratory rate of 11 breaths/min is cause for concern; any rate slower than 12 breaths/min is a sign of magnesium sulfate toxicity. A urinary output of 100 mL/hr is adequate; output of less than 30 mL/hr indicates inadequate excretion of magnesium sulfate and the potential for toxicity. The maternal blood pressure is not directly related to magnesium sulfate administration or toxicity; however, decreased blood pressure indicates that the treatment has been effective. A pulse rate of 80 beats/min is an expected pulse rate, not an indicator of toxicity.

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. A. Headache B. Constipation C. Abdominal pain D. Vaginal bleeding E. Visual disturbances

A. Headache C. Abdominal pain E. Visual disturbances Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Visual disturbances in severe preeclampsia are related to retinal edema. Constipation and vaginal bleeding are not related to preeclampsia.

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. A. Monitoring deep tendon reflexes B. Assessing urine output every 8 hours C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside F. Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min

A. Monitoring deep tendon reflexes C. Maintaining a dark, quiet environment D. Using a pump to regulate the medication E. Having calcium gluconate available at the bedside Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the primary healthcare provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary healthcare provider.

A client with preeclampsia has a prescription for a magnesium sulfate infusion to be initiated. The nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply. A. Patellar reflex B. Output of urine C. Respiratory rate D. Body temperature E. Urine specific gravity

A. Patellar reflex B. Output of urine C. Respiratory rate A baseline measurement of the patellar reflex should be obtained, because magnesium sulfate is a central nervous system depressant; an absence of patellar reflexes indicates magnesium sulfate toxicity. Magnesium sulfate is excreted by way of the kidneys; adequate urine output is necessary to prevent toxicity. Magnesium sulfate is a central nervous system depressant; a slowed respiratory rate is a sign of magnesium sulfate toxicity. Magnesium sulfate does not affect body temperature. The urine specific gravity test is not used before, during, or after magnesium sulfate therapy.

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. A. Restricting visitors B. Limiting fluid intake C. Preparing for a precipitate birth D. Maintaining a quiet environment E. Keeping magnesium gluconate at the bedside

A. Restricting visitors D. Maintaining a quiet environment Visitors should be limited to significant others to reduce excessive stimuli that could precipitate a seizure. A quiet room helps reduce stimuli and therefore the risk of seizures. Fluid intake should not be restricted. A precipitous birth is not a usual side effect of magnesium sulfate therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be readily available if signs of toxicity appear.

Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. What should the nurse do next? A. Stop the infusion of magnesium sulfate and notify the primary healthcare provider. B. Administer calcium gluconate, because it is an antidote to magnesium sulfate. C. Continue the magnesium sulfate infusion, because the blood pressure is still high. D. Check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary.

A. Stop the infusion of magnesium sulfate and notify the primary healthcare provider. Near-toxic levels of magnesium sulfate are suggested by the disappearance of the knee-jerk reflex and by depressed respirations (fewer than 12 breaths/min). This is a life-threatening situation, and the primary healthcare provider must be notified immediately. Calcium gluconate may be given as an antidote, but the infusion of magnesium sulfate must be stopped first. Magnesium sulfate is not an antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention

A nurse is teaching a client with preeclampsia regarding methods for improving her health. What is the most therapeutic instruction for the nurse to provide this client? A. "Eat a sodium-restricted diet." B. "Walk at least 1 mile (2.2 km) every day." C. "Rest often in the side-lying position." D. "Limit fluid intake to 1000 mL daily."

C. "Rest often in the side-lying position Rest is advised to reduce arteriolar spasm, and the side-lying positionpromotes more efficient venous return to the heart; this improves cardiac output and placental perfusion. Sodium is necessary to maintain circulatory volume and should not be restricted in the diet. Excessive walking is contraindicated; too much walking may increase general arteriolar spasm. Fluid restriction is contraindicated, and, because of the increased circulatory volume during pregnancy, the client needs 2000 mL of fluid per day.

Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? A. Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. B. Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. C. Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. D. Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion.

A. Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. In the left-lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase. Maximizing intra-abdominal pressure on the iliac veins will decrease, not increase, blood flow to the pelvic area. Maximizing aortic compression will decrease, not increase, uterine blood flow. Hemoconcentration occurs and uterine perfusion decreases in the standing and sitting positions.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician.

B. Gather supplies needed which will include petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician.

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

B. The lung may have re-expanded or there is a kink in the system.

An intravenous infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dosage is twice the usual adult dosage. When a nurse questions the dosage, the primary healthcare provider insists that it is the desired dosage and directs the nurse to administer the medication. How should the nurse respond to this directive? A. Administer the dose and monitor the client. B. Withhold the dose and notify the nurse manager. C. Administer the dose and document it on the client's record. D. Withhold the dose and notify the director of the obstetric department.

B. Withhold the dose and notify the nurse manager. To administer the incorrect dose would be an act of negligence that could endanger the client, and the nurse would be liable. If the dosage is not changed after the primary healthcare provider is questioned, the nurse should contact the nurse manager. The medication should be withheld, because it could cause respiratory depression and endanger both the client and fetus. The nurse should follow hospital protocol and notify the nurse manager, not the director of the obstetrics department, first.

The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? A. Boggy uterus B. Hypovolemic shock C. Multiple vaginal clots D. Bleeding at the venipuncture site

D. Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further

The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L (0.30 mmol/L). What is the next nursing action? A. Stopping the infusion B. Assessing the client's deep tendon reflexes C. Assessing the client's level of consciousness D. Documenting the level in the client's electronic medical record

D. Documenting the level in the client's electronic medical record Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. The therapeutic range for magnesium for the preeclamptic client is 4 to 7 mEq/L (0.28 to 0.44 mmol/L). The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear.

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? A. Gravida III with twins B. Gravida V with endometriosis C. Gravida II who had a 9-lb baby D. Gravida I who has had an intrauterine fetal death

D. Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.

A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What objective clinical finding indicates an impending seizure? A. Persistent headache with blurred vision B. Epigastric pain with nausea and vomiting C. Spots and flashes of light before the eyes D. Rolling of the eyes to one side with a fixed stare

D. Rolling of the eyes to one side with a fixed stare Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure. Persistent headache with blurred vision, epigastric pain with nausea and vomiting, and spots and flashes of light before the eyes are all clinical manifestations of severe preeclampsia, not eclampsia.

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

Epigastric pain is associated with the liver involvement of HELLP syndrome. TEST-TAKING TIP: When the liver is deprived of sufficient blood supply, as can occur with severe preeclampsia, the organ becomes ischemic. The client experiences pain at the site of the liver as a result of the hypoxia in the liver.

A 36-year-old primigravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, which nursing intervention is of the highest importance at this time? A. Assessing the fetal heart rate for tachycardia B. Promoting adequate urine output by offering oral fluids C. Monitoring respiratory status and ascertaining that calcium gluconate is at the bedside D. Notifying the primary healthcare provider regarding the epigastric pain, headache, and blurred vision

Epigastric pain, blurred vision, and headache are prodromal symptoms of eclampsia in a client with preeclampsia. Minimal urine output in 8 hours would be 240, or 30 mL/hr. The risk for a tonic-clonic seizure increases dramatically, and death is possible. Because the client is receiving a central nervous system depressant, it is more likely that the fetal heart rate will be decreased. The client is usually on nothing-by-mouth status during magnesium sulfate administration, particularly with unstable clinical findings, because of the possible need for an emergency cesarean birth. Although it is important to monitor the client's respirations and to ensure that calcium gluconate (magnesium sulfate antagonist) is available, neither is the priority in a life-threatening situation.

(nurse sarah) Select all the signs and symptoms associated with placenta previa: A. Painless bright red bleeding B. Concealed bleeding C. Hard, tender uterus D. Normal fetal heart rate E. Abnormal fetal position F. Rigid abdomen

The answer is A, D, and E. These are all sign and symptoms of placenta previa. The other options are associated abruptio placentae.

(nurse sarah) You're performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of the following assessment findings would you immediately report to the physician? A. Oozing around the IV site B. Tender uterus C. Hard abdomen D. Vaginal bleeding

The answer is A. Oozing around the IV site can indicate the patient is entering into DIC (disseminated intravascular coagulation) because clotting levels have been depleted. Therefore, the MD should be notified. Option B, C, and D are findings found in this condition, but Option A is a SEVERE complication that can develop from it.

(nurse sarah) A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you're educating the patient about the condition and self-care. Which statement by the patient requires you to re-educate the patient? A. "I will avoid sexual intercourse and douching throughout the rest of the pregnancy." B. "I may start to experience dark red bleeding with pain." C. "I will have another ultrasound at 32 weeks to re-assess the placenta's location." D. "My uterus should be soft and non-tender."

The answer is B. All the other options are CORRECT about partial placenta previa. Option B is WRONG because this condition will present with PAINLESS, bright red bleeding NOT with pain and dark red bleeding, which happens in abruptio placentae.

(nurse sarah) A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the placenta is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE about this finding: A. This is known as marginal placenta previa. B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated with another ultrasound at about 32 weeks gestation. C. The patient will need to have a c-section and cannot deliver vaginally. D. The woman should report any bleeding immediately to the doctor.

The answer is C. All the other options are CORRECT. Option C is FALSE. This is a type of placenta previa called marginal (or low-lying). There is a chance the woman can delivery vaginally, but if the placenta was completely over the cervix or partially covering it a c-section would be required. At the 20 week ultrasound the location of the placenta is detected. The location will be re-evaluated at about 32 weeks. If a placenta is found to be low lying there is a chance the placenta will move upward (away from the cervix) as the uterus grows to accommodate the baby

(nurse sarah) Which statement is TRUE regarding abruptio placenta? A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the cervical opening. B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical opening. C. Nursing interventions for this condition includes measuring the fundal height. D. Fetal distress is not common in this condition as it is in placenta previa.

The answer is C. All the other options are INCORRECT.

(nurse sarah) Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are released into mom's circulation, leading to clot formation and then clotting factor depletion. A. Placenta previa, fibrinogen B. Placenta previa, platelets C. Abruptio placentae, fibrinogen D. Abruptio placentae, thromboplastin

The answer is D.

(nurse sarah) A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can present with abruptio placentae? Select all that apply: A. Decrease in fundal height B. Hard abdomen C. Fetal distress D. Abnormal fetal position E. Tender uterus

The answers are: B, C, and E. Option A is wrong because there may be an INCREASE in fundal height (not decrease) due to concealed bleeding. Option D is wrong because this tends to occur in placenta previa because the placenta attaches too low in the uterus at the cervical opening.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. elevated D-dimers b. elevated fibrinogen c. reduced prothrombin time (PT) d. reduced fibrin degradation products (FDPs)

a. elevated D-dimers The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

Lilly, a single mother of four, comes to the crisis center 24 hours after a fire in which all the houses within a one-block area were wiped out. All of Lilly's household goods and clothing were lost. Lilly has no other family in the area. Her efforts to mobilize assistance have been disorganized, and she is still without shelter. She is distraught and confused. You assess the situation as: a. A maturational crisis. b. An adventitious crisis. c. A crisis of confidence. d. An existential crisis.

b. An adventitious crisis

Which goal should be addressed initially when providing care for 10-year-old Harper who is diagnosed with posttraumatic stress disorder (PTSD)? a. Harper will be able to identify feelings through the use of play therapy. b. Harper and her parents will have access to protective resources available through social services. c. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts. d. Harper and her parents will demonstrate an understanding of the personal human response to traumatic events.

c. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a.Administer morphine sulfate 4 mg IV. b.Give acetaminophen (Tylenol) 650 mg. c.Infuse normal saline 500 mL over 30 minutes. d.Schedule complete blood count and coagulation studies.

c.Infuse normal saline 500 mL over 30 minutes. The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.