Unit 3: NCLEX RN DIC, Eclampsia, HELLP, Placental Abruption

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1.A temperature of 100.4° F (38° C) 2.An increase in the pulse rate from 88 to 102 beats per minute 3.A blood pressure change from 130/88 to 124/80 mm Hg 4.An increase in the respiratory rate from 18 to 22 breaths per minute

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

A client with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse is reviewing the laboratory results and determines that which magnesium level is within the therapeutic range? 1.1 mEq/L (0.5 mmol/L) 2.3 mEq/L (1.5 mmol/L) 3.5 mEq/L (2.5 mmol/L) 4.10 mEq/L (5 mmol/L)

3 The therapeutic range for magnesium sulfate is 4 to 7 mEq/L (2 to 3.5 mmol/L); 1 mEq/L (0.5 mmol/L) and 3 mEq/L (1.5 mmol/L) are low values and 10 mEq/L (5 mmol/L) is an elevated value.

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1.Hypertension 2.Low-grade fever 3.Generalized edema 4.Increased pulse rate

1 A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1.Administer oxygen by face mask. 2.Clear and maintain an open airway. 3.Administer magnesium sulfate intravenously. 4.Assess the blood pressure and fetal heart rate.

2 The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? 1.A private room across from the elevator 2.A semiprivate room across from the nurses' station 3.A private room 2 doors away from the nurses' station 4.A semiprivate room with another client who enjoys watching television

3 A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room 2 doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia. The client with severe preeclampsia requires intense nursing observation and care.

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1.A primigravida with abruptio placenta 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 4.A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

1,3,5 In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1.Elevate the client's legs. 2.Massage the fundus until it is firm. 3.Ask the client to turn on her left side. 4.Push on the uterus to assist in expressing clots.

2 If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the primary health care provider (PHCP). The nurse should tell the woman to call the PHCP if which occurs? 1.Urine test is negative for protein. 2.Fetal movements are more than 4 per hour. 3.Weight increases by more than 1 pound in a week. 4.The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.

3 The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (3 or fewer movements per hour) may indicate fetal compromise and should be reported.

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? 1.The client is 28 years of age. 2.This is the second pregnancy. 3.The client has a history of hypertension. 4.The client performs moderate exercise on a regular daily schedule.

3 Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? 1.Placenta previa 2.Polyhydramnios 3.Abruptio placentae 4.Gestational hypertension

3 Trauma increases the incidence of miscarriage, preterm labor, abruptio placentae, and stillbirth. Careful evaluation of mother and fetus after any incident of trauma is essential. Placenta previa indicates that a placenta is implanted in the lower uterine segment near or over the internal cervical os. Risk factors that may precipitate placenta previa are not related to a traumatic event. Polyhydramnios is a term for excessive amniotic fluid, which would develop over time and not be a result of trauma. Although a motor vehicle crash may increase a woman's blood pressure, she would not be a candidate for gestational hypertension only because of the traumatic event.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1.Soft abdomen 2.Uterine tenderness 3.Absence of abdominal pain 4.Painless, bright red vaginal bleeding

2 Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.

The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. 1.Soft uterus 2.Abdominal pain 3.Nontender uterus 4.Firm uterus by palpation 5.Painless vaginal bleeding

2,4 Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized or diffuse over 1 region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? 1.Urinary output of 20 mL 2.Deep tendon reflexes of 2+ 3.Fetal heart rate of 120 beats/minute 4.Respiratory rate of 10 breaths/minute

4 Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the health care provider needs to be notified and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura

4 Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1.Tongue blade 2.Percussion hammer 3.Potassium chloride injection 4.Calcium gluconate injection

4 Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest priority item. Potassium chloride is not related to the administration of magnesium sulfate.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated

1,2,3,4 Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.

The nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation? 1.The magnesium sulfate is effective. 2.The infusion rate needs to be increased. 3.The woman is experiencing cerebral edema. 4.The woman is experiencing magnesium excess.

4 Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden decrease in fetal heart rate or maternal heart rate or both, and sudden drop in blood pressure. An absence of reflexes indicates magnesium excess and toxicity. The infusion rate, therefore, would not be increased. Hyperreflexia indicates increased cerebral edema.

A client diagnosed with severe preeclampsia is receiving magnesium sulfate by continuous intravenous infusion. Which assessment finding would indicate that the medication should be discontinued? 1.Absence of deep tendon reflexes 2.Respiratory rate of 16 breaths per minute 3.Urinary output of 45 mL during the past hour 4.Decrease in blood pressure from 180/100 mm Hg to 150/90 mm Hg

1 Signs of magnesium toxicity include central nervous system depression. The respiratory system will fail with the absence of deep tendon reflexes if this condition is not corrected. The client should maintain a respiratory rate at or greater than 16 breaths per minute (or per agency protocol), maintain the presence of deep tendon reflexes, and maintain a urinary output greater than 30 mL/hour. A decrease in blood pressure is a positive finding because preeclampsia is accompanied by hypertension.

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1.Monitor for fetal movement. 2.Monitor the maternal blood glucose. 3.Instruct the client to maintain complete bed rest. 4.Instruct the client to restrict dietary sodium and any food items that contain sodium.

1 A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1.Delivery of the fetus 2.Strict monitoring of intake and output 3.Complete bed rest for the remainder of the pregnancy 4.The need for weekly monitoring of coagulation studies until the time of delivery

1 Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1.Assess for signs and symptoms of labor. 2.Assess the client's temperature every 2 hours. 3.Schedule a daily ultrasound to assess fetal movement. 4.Schedule a nonstress test every 4 hours to assess fetal well-being.

1 As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1.Massage the fundus. 2.Document the findings. 3.Contact the obstetrician. 4.Assist the client to ambulate

1 If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Documenting the findings is an appropriate action but is not the initial action. Contacting the obstetrician is not an initial action; however, the obstetrician would be contacted if the massage does not contract the uterus. Ambulating the client could be harmful and cause bleeding.

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1."My vision for the past 2 days has been really fuzzy." 2."The swelling in my hands and ankles has gone down." 3."I had heartburn yesterday after I ate some spicy foods." 4."I had a headache yesterday, but I took some acetaminophen and it went away."

1 Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.Proteinuria 2.Hypertension 3.Low-grade fever 4.Generalized edema 5.Increased pulse rate 6.Increased respiratory rate

1,2 The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1.Uterine tenderness 2.Acute abdominal pain 3.A hard, "board-like" abdomen 4.Painless, bright red vaginal bleeding 5.Increased uterine resting tone on fetal monitoring

1,2,3,5 In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. 1.Assess blood pressure. 2.Check the urine for protein. 3.Assess deep tendon reflexes. 4.Discuss the need for hospitalization. 5.Teach the importance of keeping track of a daily weight.

1,2,3,5 With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the woman would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition.

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1.Petechiae 2.Hematuria 3.Increased platelet count 4.Prolonged clotting times 5.Oozing from injection sites 6.Swelling of the calf of 1 leg

1,2,4,5 DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. The presence of petechiae, hematuria, and oozing from injection sites are signs associated with DIC. Swelling and pain in the calf of 1 leg are more likely to be associated with thrombophlebitis.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1.Flushing 2.Hypertension 3.Increased urine output 4.Depressed respirations 5.Extreme muscle weakness 6.Hyperactive deep tendon reflexes

1,4,5 Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

The senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The co-assigned registered nurse asks the student to describe the actions and effects of this medication. Which statement, if made by the student, indicates the need for further teaching? 1."It decreases the frequency and duration of uterine contractions." 2."It increases acetylcholine, blocking neuromuscular transmission." 3."It decreases the central nervous system activity, acting as an anticonvulsant." 4."It produces flushing and sweating due to decreased peripheral blood pressure."

2 Magnesium sulfate produces flushing and sweating because of decreased peripheral blood pressure. It decreases the frequency and duration of uterine contractions and decreases central nervous system activity, acting as an anticonvulsant. Magnesium sulfate decreases (not increases) acetylcholine, blocking neuromuscular transmission.

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1.Restrict food and fluids. 2.Reduce external stimuli. 3.Monitor blood glucose levels. 4.Maintain the client in a supine position

2 The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the primary health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply 1.Proteinuria of 3 + 2.Respirations of 10 breaths per minute 3.Presence of deep tendon reflexes 4.Urine output of 20 mL in an hour 5.Serum magnesium level of 4 mEq/L (2 mmol/L)

2,4 Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3 + is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L).

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1.Urinary output has increased. 2.Dependent edema has resolved. 3.Blood pressure reading is at the prenatal baseline. 4.The client complains of a headache and blurred vision

4 If the client complains of a headache and blurred vision, the PHCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? 1."I don't like my figure anymore. My clothes are all too tight." 2."I don't like my breasts anymore. These silver lines are ugly." 3."I don't like my stomach anymore. That brown line is disgusting." 4."I don't like my face anymore. I always look like I have been crying."

4 In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent.